Telemedicine in India

Manisha Iyer, Nikhil Dev, Jose K JoyInformation & Interface Design

Guide: Dr. Bibhudutta Baral

Telemedicine in India: Introduction

Telemedicine is the use of information communication technology for the delivery of health care services to areas where public health services are below the required levels. It has enormous potential for increasing the access to medical services by increasing the reach. In India with 75% of the Indian population live in villages. But 75% of the doctors practise in Urban areas, 23% in Semi Urban areas and only 2% percent of the doctors in villages where 75% of the population lives. All incentives to to entice the doctors to serve in the rural areas have failed. This inequitable health scenario in India

Telemedicine in India uses broadly two types of technology- the store and forward tech-nology, where the patient information is stored and sent to the Specialist centre where the specialist doctor gives his diagnosis. And the real time streaming where a video conference is used to provide live consultations by Specialists to patients in remote areas.

Village Population

Rural Population

Doctors in Villages

Doctors in Urban areas

Doctors in Semi Urban

Need for Telemedicine

Home Care&

Ambulatory

TelemedicineApplication

Remote Consultation & Critical CareMonitoring

DiseaseSurveillance &

Programtracking

ContinuingMedical

Education &Public Awareness

DisasterManagement

Telementoredprocedures/

Surgery -Robotics

Second Opinion &Complex Interpretations

DiseaseManagement

Review of Literature Introduction:

From our primary research on healthcare we found that telemedi-cine was an upcoming �eld in India and could play a major role in making healthcare accessible and a�ordable. It involves a lot of interaction between people and technology, and we wanted to enquire into the interaction and delivery of the service, to �nd design opportunities for improving the same.

For this purpose we needed to have a thorough understanding of the current scenario. We did some googling and found our starting point at www.telemedindia.org. This site is maintained by School of Telemedi-cine and Biomedical Informatics, SGPGIMS, Lucknow, India and SONY. This site gave a very good overview of what tele-medicine is, about equipments and softwares, Telemedicine initiatives by the Govt and others, Policies and Guidelines etc. It also give us some important cues on the implementing agencies- ISRO implementing the largest telemedicine initiative in the country covering more than 200 rural & district hospitals, Apollo’s Telemedicine Network Foundation, Narayanayala Hrudhayalaya’s telemedicine network etc, Shankar Netralaya’s teleophthalmology network etc.

Need for home-telehealth/ Connected health: - To make health care accessible to the elderly and patients who cannot travel. - Increasing costs of hospitalization - Shortage of health care providers - For management of Chronic diseses like diabetesBesides the above mentioned reasons in the article we found the following also to be the need for connected health: - Proving timely care - Making patients more involved in their own Helth (Self Management) - Home environment speeds recovery - Travelling in tra�c takes too much time these daysTwo approaches for remote monitoring used, mentioned here is the telephone and telemonitering. In the �rst approach, a nurse replaces the in-house visit with a weekly telephone call, during which the nurse reviews the patient’s status, and counseling and educational support are o�ered to the patient. The challenge that has surfaced with this system is the reliability of patient self reporting. In the telemonitoring method, Daily measures of body weight and blood pressure are recorded via sensors, which transmit the data wirelessly to an inter-face unit in the patient’s home. The information is then transferred to central servers for further evaluation by the patient’s healthcare provider. Patients can connect with their healthcare provider through email, and some o�er videoconfer-encing capabilities so that patients and physicians can hold direct teleconsulta-tions. We feel, this scheme is highly technology based, and needs a little getting used to by any elderly user. Using wearable sensors which monitor the vital stats continuously is another option which can get irritating and uncomfortable at some point.Thus we feel this technology would best suit for a short duration and would not be very well suited for constant use.

Home telehealth: the future of home careShereene Z. Idriss Partners Telemedicine

Home Health Care via TelemedicineB2BMedia Inc-Interview with Dr Mahmud oncologist & CEO of American TeleCare:

"Personal Telemedicine System" (PTS) for the home- is organized around two modules: the home unit and the nursing unit.

- The nursing unit is set up at a central nursing station, and is sta�ed by a nurse who provides electronic housecalls to multiple home units. - The system works over the "plain old telephone system" (POTS). -Thus, it operates over the ubiquitous analog phone lines, making it universally avail ablePOTS seems the best for making the facility accessible. Its bandwidth capacity is very less an cannot be used for real time teleconsultations, so it is best suited to transmit the vital stats. Dr Mahmud strongly feels that though it cannot be used to examine small wounds, the resolution of the video available for POTS is su�cient for the nurses to understand the mood and response of the patient which is su�cient for monitering patients with chronic diseases which account for the majority of patients who demand homecare. The high cost of the patient unit makes this very biased to those who can a�ord it. At the same time we observed from our research that ReMeDi is a very low cost telemedicine kit which is more a�ordable for users. What ever said and done, telemedicne in home care has its undeniable beni-�ts- there hve been proven decrease in disease progression, and it ensures to some extent that the patients’s problem does not accumulate between visits to the doctor.

An Interview with Lisa Remington (5-year veteran of strategic planning and business development for the home-health industry): According to Lisa Remington, telemedicine is the future of the home health industry. “Since we are aging as a society, and since aging people require more health care, I think it is fair to say that the only way to make the shrinking dollars �t the increasing needs is to become a lot more e�cient. Telemedicine is the only thing I see coming up that promises real improvements in e�ciency.” and she also states that “ the evidence I’ve seen suggests that the personnel savings will be much, much greater than the technology costs.”

We feel the only way personal saving in healthcare can be increased is by more contri-bution by the Govt in the public healthcare expenditure.

This paper compares the cost of telemedicine to the costs of conventional methods of health care. People are not aware of the cost e�ectiveness and the e�ciency of the telemedicine. Telemedicine in most cases is assumed to be having no outcome on the health. It explains the other factors due to which the people resist to start practicing the telemedicine.

Requirements of Telemedicine are:IT hardware, Software, Media hardware, Medical hardware, Internet Connectivity, Infrastructure, Man ware.

The cost to start a telemedicine set up is 50,000 which is very less compared to that spent for the equipments in the hospitals (millions). So cost of incorporating telemedicine is a�ordable comparatively.

Technology is no longer a barrier. Internet connectivity is there in all geographical regions of India through satellite. The bene�ts of telemedicine are already proven in many places. The thing is that nobody takes initiative due to certain factors as below.

The goals set up before starting a telemedical set up are: Political gain, Improved quality of care, Business pro�t

Key considerations : Visible are - Quality of care , Patient safety, Patient satisfaction, Practitioner productivity, Practitioner satisfaction, Financial return, process.Invisible are - Political need, Social need, End user indulgence, Sta� indulgence, Inter/intra departmental politics.

Cost factors:

Visible – hardware, software, connectivity, man ware, training, operational management, support.Unseen – Lobbying, publicity, misuse, damage.

Thus nobody takes risks to start the centres which may become a burden to them due to the management failure as well as the external factors as mentioned above.

Few telemedicine centres started in India stopped working after �ve years. These were setup only for the political gain of the MLA or the government. Government pays to set up the centre. Some private hospitals provide services and consultations. Patient gains improved quality of service. Government gains good publicity. After �ve years the ruling party changes and thus it won’t get any support further. Has it been good for the economy of that village for that �ve years? Yes. But has it made any pro�t for the telemedical centre or the system? No. A good business plan can make money through telemedicine. Then there may be a lot of people taking initiative to start centre and all.

The model can be: technology based model implementation based model or a business based model.

Adopting cost e�ective or innovative solutions can attract the service providers. A patient spends a lot of money in a speciality hospi-tal. If a nursing home near to his home can provide the same service through telemedicine he would de�nitely prefer this option. He feels comfortable and is cost e�ective. Support with bank loans, extending the hand hold period etc. can be tried in a business model. So an e�ective model can solve the problems in the existing system of telemedicine in India.

Economics of Telemedicine by Dr. D Lavanyan, MBBS,MD CEO & MD, HCIT Consultant

The Telecommunication Technologies in use as mentioned were T-1, ISDN, POTS and Internet, but we observed that T-1 is quiet unheard of in India, and internet facility is available only in urban and semi urban areas. Whereas Plain Old Telephone Service, since it can have only 56kbps, can support only store and forward and cannot be used for real time tele-health.

The paper presented various applications in Public Health, which we did not come across in other literature studies, in Epidemiological Surveillance & in Interactive health communications and disease prevention. - “It (telemedicine) can give new insight into geographical distribution and gradi-ents in disease prevalence and incidence and valuable insight into population health assessment.” - “It can play a pivotal role in anticipating epidemics.” This can be possible by study-ing the electronic medical records of the population and make a combined assessment of the health of the society. - “Information technology and telemedicine can be used to inform, in�uence and motivate individuals and population organizations on health, health-related issues and adoption of healthy lifestyles. ” - It promotes self-care and domiciliary care practices”,”- It can be a very important tool for the evaluation and monitoring of healthcare services.”A key point in under Telemedicine in India section was that about the Failure of all incen-tives for specialists to practise in rural areas. This we felt was the major cause for the ineq-uity of healthcare in India.Current E�orts (was as mentioned in the telemedindia.org web site) are supported by Govt: DIT, ISRO NEC, private : Apollo, Narayana Hrudhayalaya, State Govts, other private organizations,Initiatives by DIT, C-DAC software, and a detail of ISRO’s Network is again mentioned.

Telemedicine Concepts

- Telemedicine Consultation centre(TCC) TCC is the site where patient is present. Here all the equipments for scanning and communicating the patient’s medical information is present.

- Telemedicine Speciality centre(TSC) Is the site where the specialist is present

- Telemedicine System - Hardware -computer -printer -scanner -video conferencing equipment - Software Enables aquisition and processing of the patient information -Communication Channel

“Telemedicine: A New Horizon in Public Health in India” by Aparajita Dasgupta, Soumya Deb

The paper “Telemedicine: A New Horizon in Public Health in India” by Aparajita Dasgupta, Soumya Deb gave a lot of relevant de�nitions relating to telemedicine such as Telemedicine Consultation centre , Telemedicine Specialty Centre (TSC), Telemedicine System and also described the two types Technologies used : - Store and Forward - Real Time which were mentioned in almost all Literatures.

Regarding Telemedicne Infrastructure, The Telemedicine Centres are classi�ed as:Primary Telemedicine Center (PTC)Secondary Telemedicine Center (STC)Tertiary Telemedicine Center (TTC)

Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, INDIASGPGIMS is a medical college in Lucknow practising distance medical education through their telemedicine network for last ten years. SGPGIMS Telemedicine Program is using various kind of high bandwidth communication network such as satellite based communication provided by ISRO, Lease line through terrestrial �bre optic network and Integrated Services Digital Network (ISDN) to connect the district hospitals in rural and remote hilly areas, medical colleges and tertiary level hospitals for medical knowledge exchange. The process has started in September 2001 and is continuing in steady pace. Encouraged with active participation by the stake holders, SGPGIMS has been expanding its telemedicine network with willing partners across the country and South Asian region aiming at bridging the knowl-edge and skill gap among students, teachers, practitioners, public health and paramedical professionals involved in healthcare at tertiary, secondary and primary level.

SGPGIMS carried out 1309 tele education sessions between 2001 to 2009 for training and teaching of the students, medical teachers and practicing doctors. The tele education modules practiced areTele-education for postgraduate students of medical colleges,Tele-education for district hospital doctors,Training of Medical Professionals and skill transfer (Tele-mentoring),Tele-CMEs (Continuing Medical Education).

In India most of the tele-educational activities are running in project mode. Very few medical colleges / institutes like SGPGIMS Lucknow, AIMS Kochi, CMC Vellore, PGIMER Chandigarh, SRMC Chen-nai, AIIMS New Delhi have now integrated this mode of knowledge exchange into their routine educational program at postgraduate level. The emerging technologies like virtual reality, telepresence, simulation based skill development will increase the scope of medical education and thus the service. The technical ministries of the govern-ment took the initial lead e.g. Department of Information Technology (DIT), Ministry of Communication and IT, Indian Space Research Organization (ISRO) carried out the pilots by providing the technology and funding the projects. Corporate hospitals also made investments in tele-health infrastructure e.g. Apollo Telemedicine Network Founda-tion, Chennai by the Apollo Hospital group, Narayana Hrudayalaya, Bangalore etc. Telemedicine is basically providing service to remote areas using the electronic information and telecommunication technolo-gies. It makes services accessible and a�ordable. Thus there is a great need of medical professionals and doctors who can handle the tech-nology. The future of health care may be better through telemedicine. The institutes like SGPIMS have long vision and are providing medical education on telemedicine. Thus such initiatives should be given funds and assistance from the government and should be highly appreci-ated.

Technology Critical Issues in Medical Education and the Impli-cations for Telemedicine

by Ashok Kumar Mahapatra, Saroj Kanta Mishra, Lily Kapoor, Indra Pratap Singh - School of Telemedicine & Biomedical Informatics,Sanjay Gandhi

This paper discusses the recent advances in the mobile broadband technology, context-aware, P2P data grid framework for mobile telemedicine. It also gives a clear picture of the usability of wireless technologies in telemedicine systems. First of all, the paper discuses about the current telemedicine system and its applications as discussed earlier. As the number of telemedicine units increases, the centre at the big hospital may become a bottleneck. The privacy also can be an issue. The main challenge of the system is the problem with involving patients during emergencies. The main problem faced by patients is the di�culty in travelling to the hospital and back.Then it discusses about the mobile technologies such as Wi-Fi, WiMAX, Bluetooth and ZigBee. How to make an interaction between medical sensors and communicating will be a big problem. The doctor will be equiped with a mobile phone or PDA which is capable of receiving wireless medical information like ECG and other imaging. There will be a pre-con�gured software installed in the mobile which can schedule incoming signals and interrupt doctor accordingly. By integrating health insurance, blood banks, ambulance etc. into the grid, we can make a full-�edged health grid covering the entire country that can provide a whole lot of medical services. Such a health grid will be of immense help to the developing nations.

Mobile Telemedicine using Data Grid by Sriram Kailasam, Santosh Kumar, and D. Janakiram

Research Methodology

Sources

ImplementationExperts

End Users

Abhay Singavi, CEO NarayanaHrudhyalaya

Lakshman, Telemedicine Dept, NarayanaHrudhayalaya

NandhkishoreDhomne, CIO,Manipal Hospitals

Pradeep, Telemedicine Dept,Apolllo Hospitals

Technonlogy Users

Technology/Equipment

Expert

Khemchandra Birhade, Vice-President,

Business Development,NeuroSynapics

Sister Greta,HomeCare, Manipal Hospital

Mr. Jagdeesh, Patient, Apollo Hospital

Mr. Roy, Patient, Apollo Hospital

Ms Shiney, Manager, HomeCare, Manipal

Hospital

They adopted a lot of innovative delivery models which was very cost e�cient- eg) they made use of the Postal service to deliver medical reports at the doorstep of every individual! It was an inspiring meeting!!! Form his interview we located a few key areas in telemedicine delivery in India where not much had been explored- icu monitor-ing, ambulance monitoring and mainly homecare telemedicine where patients could have access to health care from their homes, this as they identi�ed could also help in reducing the hospitalization time and provide the comfort of home to the patient. This becomes a win-win situation for both parties.Now that we had some expert opinion, we wanted to approach the patients and clinicians whom formed the End Users of this technology. Here we faced some di�culty as Bangalore being a metropolitian city, has hardly any villages. The rural areas, where the telemedicine end users were located were too far away for us to access. But after some more research we were able to locate local patients and were able to interview them. We also approached other stakeholders and service providers. We tried contact-ing ISRO, C-DAC, CISCO and others but with little success. We contacted NeuroSynaptics which turned out to be a goldmine of a resource. They were experts at manufacturing low cost innovative telemedicine technology. Though they were initially quiet hesitant about sharing their work, in the end they really opened up and shared with us their they methodology and procedures. From NeuroSynaptics we understood the shortcomings in the existing system of Telemedicine delivery which we could not �nd in any literature. We understood that in India there is very little Direct doctor to patient telemedicine services- almost everywhere the patient must go to clinic where there is a clinician or a general physician who connects the the patient to the remote specialists over telemedi-cine. There is very little being done in Home based Telemedicine where there is direct connection between the patient and the service provider- This was the same view that Narayanaya Hrudhyala also had.Thus this overlap of “need for attention in HomeCare Telmedicine” gave us a direction to focus our research on the same. Thus we started out again on a whole new literature study on HomeCare Telemedicine in India. Since this concept was only emerging in India there are not many papers from India, but we read up papers from other countries and found that many of the existing methods and models there can be easily adapted and brought into the Indian context, at least for the urban areas of the country where technology has penetrated reasonably well. These models can be revamped in forthcoming iterations to suit the rural areas too.

From our literature review we found out Apollo, Narayana Hrudhayalaya and Manipal hospitals were the biggest telemedicine implementers in India. We realized these places would give us a real picture of Telemedicne in India, and decided to base our research on them.

As we did not have any contacts we spent a lot e�ort in �nding resource-ful links. We sent e-mails and made appointments. Many of whom we met (especially Mr Abhay Singavi CEO of Narayanaya Hrudhyala )were CEOs and CIOs, and were able to share great insights into the working of Telemedicine that we could not have found anywhere else. They had very good knowledge about the subject and were very passionate about it, and were happy to share their knowl-edge with us. Meeting those people not only have us a better understanding of the subject, but also really motivated us and brought in a sense of purpose behind the research. Narayanaya Hrudhyala has the world’s largest telemedicine network and they provided this service absolutely free of charge.

Apollo Hospital

TeleMedicine at Apollo Hospital,Banglore

Apollo Hospital

Apollo Hospital

From our interview with Mr. Praveen Kumar, we understood that in Apollo Hospital Banga-lore, Telemedicine is happening only within the Apollo Group of Hospitals. We realized that Telemedicine is not just used for the bene�t of rural areas but also to facilitate intra hospital medical networking.

Since the facility is available only to patients who come to the hospital, the reach of its service is not as much as it could have been if they had dedicated telemedicine centres spread across the city, or even better, the villages. Since Apollo itself is a speciality hospital, there hardly arises any circum-stance where one needs more speciality care, thus Telemedicine has hardly any role to play. Because of this there is no dedicated department for Telemedicine.

Generally the only occasion where a patient uses a telemedicine service is when he has relocated from his home town and wants to meet his family doc back in town. Instead of travelling all the way back to his home town, he could just visit the same hospital group in his current location and request for telemedicine consultation with his family doc. This way he saves a lot (time, e�ort and money) on travel.

Tele-consultations and tele-diagnosis are being given in almost all medical �elds and Mr Praveen observes that tele-neurology has the most takers. They have simple procedure of going about it: When a patient requests a telemedicine session, the telemed dept gets an appointment for him. A day before the appointment, the patient records are emailed to the concerned doctor. The patient is expected to report half an hour before the appointment.(Apparently they don’t support Emergency care!) The technician establishes the connection with the other centre which is online. Once the connection is established, the patient can see the doc on the screen and speak to him real time and get medical advice.

Apollo hospitals all over use the PolyCom Vedio conference services as it the most economi-cal of all the choices available in the market today. It is connected across by ISDN or by Static IP. During the tele-consultation, if the doc prescribes some tests, it is locally performed and the results are sent to the doc over email system separately. Even the patient records and �les are sent seperat-ley to the doc by the records department over the internet. The prescription prescribed the doc again is faxed or email separately. (Here we perceived an opportunity to integrate all these related individual tasks such that all of them can be performed by the same Telemedicine equipment. ) The patient is charged as much as for the Tele-consultation as the regular consultations. Although Apollo Banglore does not haveassociations with other hospitals or health clinics, there have been some tele-consultations provided to some centres in Iraq , Nigeria and Mauritius

Mr. Abhay Singavi, CEO, Head of Telemedicine dept, Narayana Hrudayalaya

The main idea behind Narayana Hrudayalaya’s initiative on telemedicine,according to Abhay Singav, is that, “less than 1% of the sick requires an operation, if you do not need to operate, you don’t need to touch and if you don’t need to touch, you don’t need to be there and the best solution for this would be Tele-consultation through telemedicine. More over 1768:1 is the patient:doctor ratio in India.”The main functional areas of Apollo hospital telemedicine are, Tele-consultation, TTECG, Tele-education, Hrudaya Post, Mobile Van and PAN African e-Network.Patient requiring specialist consultation in remote center can interact directly with the specialists through video conferencing. If he needs further proceed-ings only, he will be asked to come to the specialty hospital. Till date, they did more than 30000 tele-consultations. ISRO is providing the satellite links with free of cost for this service. West Bengal, Karnataka, North-Eastern States, Andaman & Nicobar Islands, Jharkand, and Gujarat, Malaysia, Tanzania, Nigeria, Burundi, Zambia, and Bangladesh are the major focus areas. TTECG: This project is mainly for village hospitals de�cient of cardiac support.They found out that the Telephone network and the Indian Post o�ce networks as the most connected networks in this country and they connected 308 centers in India as well as abroad to their network of TTECG which is the world’s largest ECG network connectingTanzania, Afghanistan, Pakistan, Bangladesh, Mauritius and Malaysia.

CME-Tele education: They are using the tele-medicine facility to conduct academic teaching / training sessions. They have found that telemedicine proved to be e�ective in establishing communication not only between the patient & the physician but also between the teacher and the students.

“Less than 1% of the sick requires an opera-tion, if you do not need to operate, you don’t need to touch and if you don’t need to touch, you don’t need to be there and the best solution for this would be Tele-consultation through telemedicine. More over 1768:1 is the patient:doctor ratio in India.”- Abhay Singavi, CEO Preventive Health, NH

Telemedicine Initiative at Narayana Hrudhayalaya

Hrudaya Post: India has world’s largest network of post o�cesand most these post o�ces have very good connectivity including telephone connections, Internet and broadband. Through Hrudaya Post, their aim was to link all the post o�ces to the hospi-tal, so that heart patients living in small town and villages can go to any of the post o�ces and send their entire medical reports to them by scanning the medical reports and once the report reaches the hospital, their heart specialist will go through the entire �le and give the opinion. This opinion goes back to the concerned post o�ce and this will be delivered to the patient. Now they are running this project successfully in 25 post o�ces in Karnataka. Mobile van: They put all the machines in a large van, is which an Echo Machine, Thread Mill, ECG’s, de�brillator. This bus goes to the villages and meet patients, who only require to procedure its needs, ask to come to Narayana Hrudayalaya. Now they are trying to link the mobile unit to their specialty centers in Bangalore with the satellite link from ISRO. PAN African e-Network: Govt. of India and the Ministry of External A�airs made use of the Pan-African e-Network. The network would primarily provide e-Services with priority on Tele-education, Tele-medicine services, and VVIP Connectivity. Narayana Hrudayalaya is connected to 53 city states of Africa and is actively delivering the health care to great number of people through the aid of TCIL’s channel.

Telemedicine Initiative at Narayana Hrudhayalaya

Telemedicine Initiative at Narayana Hrudhayalaya

The Manipal Hospital Telemedicine Network works upon a “server based technology” the server is situated in Bangalore.

- All the peripheral hospitals end and user end are given a login ID through which all the members are able to get the telemedicine consultation through this network.

- Currently they are using ISDN connections. High speed data cards are been used for teleconference. These consultations will be provided by Manipal Hospital, Bangalore on a scheduled basis, which will be coordinated by team of professionals.

- Here the secondary and tertiary level of telemedicine is usually done. The patient comes to the hospital. If the doctor �nds it di�cult to carry the case, he consults with the the specialists in a remote area through the telemedicine network.

- Post and presurgery teleconsultations are done.

- No live take overs.

- Also the doctors in this hospital gives assistance to the hospitals through video conferencing. They do 10 to 12 sessions per week. - The telemedical proceedings in manipal hospital, bangalore are not very active even if it is a multi speciality hospital.

Telemedicine at Manipal hospital, Bangalore.

“Half the disease is cured when the patient just gets the doctor’s touch which is not really possible in tele-medicine.”“We are still waiting for better Tech-nology and bandwidth- 3G will de�-nately help”-Nandakishore Dhomne, C I O, Manipal hospital, Bangalore.

The discussion was helpful as he told us about the technologi-cal de�ciencies in Indian context:

- Video conferencing is not e�ective in case of surgery due to the poor Internet speed. The satellite connections available are not e�ective due to a latency of 530 ms minimum.- The image transfer should be instantaneous. - High de�nition video is needed for telesurgery.- VSAT needs huge dish antenna. - 3G can change the entire scenario but it will take time for the technology to be established and accepted as a standard.

- Mind set of people towards the upcoming technolo-gies is a key factor.

Home Care at Manipal Hospital, Banglore

- patient calls Home Care HelpLine- the logistics manager �xes up an appoinment, - trained nurses are despatched along with fully equipped mobile van- the centre is in touch with all its nurses and vehicles using mobile phones and GPS- the nurse provides the care to the patient - if required, a consultation with the doctor is made by store & fwd Telemedi-cine using the Laptops

Telemedicne: Patient’s perscective

Mr. Jagdeesh (Patient, Apollo hospitals)

Jagdeesh is a middle aged government employee. He was not aware of the telemedicine techniques and practices. He has good knowledge of technologies such as Internet and computing systems as he is using it for o�cial purpose. When we introduced the telemedicine concept, he was amazed because he can reduce travelling expenses and time. That day he had taken leave for one day and came to hospital for consultation. We understood that he represents a major popula-tion of patients.

Mr. Roy (Patient, Apollo hospitals)

This patient was aged more than 55 and he shared his di�culties in getting consultation. His son is working in a private �rm and took one day leave for taking his father to hospital. So he is feeling like he is becoming a disturbance. When we asked about the possibility of getting consultation through Internet, sitting at home, he was very happy. He said that his grandson is aware of Internet and he will help him in getting consultation. They already have all facilities such as computer, web cam, mic and Internet connection at home.

Mrs Lathika (Patient, Apollo Hospital)

Mrs Lathika is from Chennai, she has recently moved to Bangalore. Her doctor is in Apollo Chennai. She is very happy that she can consult with her own doctor who is in Chennai through Telemedicine because he has been treating her for a long time and knows her case well. She is able to save time and e�ort of making a journey to Chennai.

Ms. Prasanna (Patient, Apollo hospitals) Ms. Prasanna is a mid-aged housewife. She also shared her travel-ling problem for taking consultation. But one of her relative is a doctor. Whenever a medical problem arrives, Prasanna used to call this relative, tells the symptoms and asks for opinion. Most of the times, it works perfectly alright and Prasanna is very much comfortable with this telephonic consultation.

Mr. Raghav RajRaghav is a softaware engineer. He took leave for a day and came for consultation. He was very irritated with the problems such as tra�c blocks, queue in hospitals, in-e�ciency of the system etc. He actually gave some insights about the advancements happened in developed countries such as remote surgery, advanced sensors and applications. When we proposed the telemedicine system for home care, he was happy and he told that its impact will be more in urban areas where time and good health are the main luxuries of people.

The telemedicine available in India are in the secondary and tertiary level i.e. hospital-to-hospital as well as consultation with a super- specialist. Here there is no direct involvement of patient i.e., a patient can be connected only through a doctor to the telemedicine network. In India doctor to patient ratio is very low especially in rural areas where 70% of the Indian population resides. The telemedical setup currently available in India is not accessible to the patients in rural areas. To start a telemedicine center in rural area itself is a challenge to the medical society. The technologies developed so far are complex and videoconferencing and all requires high band width. Such facilities are not simply available and becomes una�ordable in rural/remote areas. Also the maintenance cost is high.Neurosynaptics is basically a company providing technology as well as service for the telemedical setup. They concentrate on the primary level of telemedicine i.e. directly connecting patients to the doctor from remote/rural areas

They developed a technology called ReMeDi (Remote Medical Diagnosis) in collaboration with the TeNet group of IIT Madras using embedded software appli-cations. This technology was patented and got recognized all over the world in the �eld of telemedicine, and also won the Technology Pioneer a ward 2008 at the World Economic Forum.Salient features of the product: Can measure 12 channel ECG, blood pressure, Chest and Lung sounds, and temperature and pulse rate.Includes complete video conferencing, which works on low bandwidth.Support both real time and stored forward mechanism to transfer results of various tests.Complete patient medical record management system.

What makes it di�erent?It operates on low band width of 64 kbps. It can work even at 32 kbps.It is battery operated (rechargeable), probes can be re-engineered, wireless connec-tivity with the PC and complete isolation of the patient from the AC mains.Any non medical professional can operate with minimal training.No medical data loss. I.e. accuracy.Low cost with high quality.

Due to the above features, ReMeDi can be used to implement telemedicine in rural/remote areas of India where there is very less medical and technical professionals/infrastructure.This technology is being utilized by an organization called World Health Partners (WHP) in setting up a Telemedicine network in India. Its Central Medical Facility is in Greater Kailas 2, Delhi, which connects 154 telemedicine centers in 3 districts of UP and 1 district in MP. Within 8 months they are working to set up a total of 2000 centers all over the world.The requirements with reference to their network set up in Delhi is given below.

Basic requirements of a telemedicine p-center are:

A 10 X 10 sq feet room, a PC, a webcam, mic and head phone, internet of 64 kbps, ReMeDi Medical Data Acquisition Unit (MDAU), furniture required , and an operator with a minimal operational knowledge. They are using USO scheme of BSNL, which is only for rural areas, providing cheap internet connectivity of Rs 250/month. The total cost for such a set up is between 1 and 1.5 lakh.

The requirement in the central medical facility (CMF) includes:

The CMF is expected to be built on an area of 20 X 30 Sq. feet with at least 5 X 5 sq. ft area for Server with AC arrangement. The CMF should have place to keep a Hardware Server, a Table for it. It should have backup server and good UPS and generator. Solar Power back is generally not preferred for CMF. There should be arrangement of cubical for Doctors and assistants. Each of these Doctors and assistants should be provided with desktop PC/ Laptops with proper head-phone and microphone and an internet connectivity separately (or in the LAN) of at least 128 Kbps Connections.

Telemedicne implementation by Neurosynaptics Communications

The patient visits the telemedicine center. The operator enters the prime details and connects to the CMF through internet. There is an operator at the CMF who receives the information through the server. He transfers the informa-tion to the doctor depending on the requirement or the disease of the patient through a LAN network. The patient can now directly talk with the doctor. The ReMeDi Medical Data Acquisition Unit (MDAU) can be activated only by the operator at the CMF or by the doctor. The required ports of the unit is activated depending on the diagnosis required. The operator at the rural center uses the probes and leads as per the doctor’s instruction. Either Real time, or stored-and-forward data transmission of various tests takes place depending on the case. The doctor diagnoses the disease and gives suggestions accordingly and prescribes the medicine. Probably the center itself has a pharmaceutical or there should be at least 1 pharmacy for every 2 centers depending on the distance and all. If the patient is in serious condition immediately the ambulance service is provided and he or she is been taken to the nearest hospital.

This technology can also be used in a shared platform which can further reduce the cost of setting up a center. The services like DTP, photography, e-governance, education, agriculture, veterinary care etc. also uses the basic infrastructure like PC, webcam, microphone, speaker, printer etc. Thus the equipments become fully occupied for the whole day if it is used in a shared platform.

CENTRAL MEDICAL FACILITY

RURAL HEALTH CENTRES

INTERNET CLOUD

D 1 D 2 D 3 D 4 . . . . .

SERVER

ASSISTANT

OPERATOR PATIENT

LAN NETWORKCENTRAL

ReMeDi kit & Probes.This kit is able to measure ECG, BP, Temperature, Heart & lungs sounds.

DOCTORS

64 kbps

This kit is there in each rural health centres. Can be only activated by doctor or assistant in CMF. Kit is even active in 32 kbps.

Patient walks in.

Videoconferencing

64 kbps

Data transfer

Data transfer

Working model of ReMeDi

Analysis Telemedicine has a signi�cantly increased on just the the reach accessiblity of health care but also the quality of health care. It has made health care available to the poorest of poor who would never have dreamt of getting a consultation with the specialists. It saves a lot of time, e�ort and money involved in travel for the patient.

Telemedicine used by some big Hospitals in Banglore : connects mostly hospitals belong to the same chain. It its used for providing teleconsultations, second openion, and telementoring. They donot yet provide telemedicine serv-ices to the rural areas. There are also other hospitals like narayana hrudhyla which cater to the masses- they provide telemedicine to the masses for free. More such developments and innovations are required in this �eld. For this Tele-medicine awareness must be created. There are very few institutes that include Telemedicine as part of the curriculum SGPGIMS does a lot of active R&D on Telemedicine, acts as a hub of telemedicine, is involved in a lot of events related to Telemedicne, and maintains a good web presence. There is a dearth of Educational & Research Institutes which are involved in Telemedicine. The dedicated HealthSAT provided by ISRO is one of the major technologi-cal supports for Telemedicine, which has made this service a�ordable and acces-sible to the poor needy of the most remote areas of the Nation.

Technology: Using existing technology itself to the full extent is su�cient to provide basic Telemedicine. Better technology, greater bandwidth, Expertise in using the technology is required for Providing State of the art Telemedicine service like Robotic Surgery. 3G can greatly improve the existing telemedicine scenario by providing much higher bandwidth required for video conferencing. Lot of innovative and cost e�ective technologies are being adopted like hrudayala post, TTECG, ReMeDi etc. Cisco, Seimens, GE etc have Connected health programmes for providing telemedicine.

Issues (Scope for design intervention) :• Technology has not reached most of the rural areas, many villages don’t even have electricity- this becomes a barrier for implementing Telemedi-cine.• Bandwidth and internet facility not good enough for high end telemedi-cine• Inefficient utilization of existing technology • There are interoperability issues between software.• Misuse of telemedicine resources• Maintenance issues of telemedicine centres lead to shutting down of the centres.• Political influences and issues• Very little awareness about telemedicine facility and benefits• There is no strict regulations and standards in telemedicine delivery. This is necessary for the proper • Financial support and incentives to start up & maintain centres in rural areas.• Many private hospitals are profit oriented and and donot have much programs directed at the rural areas. • Exisiting telemedicine sys concentrates mainly on Secondry and Tertiry care, very little in primary care where a patient can directly get access to the specialist.• Telemedicine has good potential in Homecare but it is not being explored currently.• People have technofear- feeling that computers would make them unemployed. • And many people are not convinced that technology can effectively help them.

Proposed Implementation Model

· Vision: Improvement in

- Accessibility, - Cost e�ectiveness, - Quality of care, - Patient safety, - Patient satisfaction.

· Research: Identify the public health care needs.

· Areas of requirement - Remote areas where the reach of medical facility is less,

- Home scenario where patients �nds di�cult to travel,- Ambulance etc.

· Funds and the implementation cost.

· Standards, authorisation, legal issues and government support.

· Whom to collaborate:- Hospitals (govt. ,pvt),- Pharmaceuticals,- Technology providers,- Government- Doctors, - Public etc.- Educational & Research institutes

· Awareness among the public about - The need of telemedicine - The technologies & services provided - Cost e�ectiveness and e�ciency - About the collaborations

· Start central medical facilities and rural health centres

· Invite local agencies to start telemedical centres.

· Support with bank loans.

· Provide primary operational training.

· Provide full support and guarantee for a long period- Technical support, Maintenance,

· Make sure that the centres functions properly- Misuse of the facilities may happen- Irresponsibility of the centre in charge

· Get feedback and improve the facilities and services.

· Introduce new technologies with time.

· Extend the number of end users by starting more centres.

· Active interaction between the stakeholders of the system.

· A committee to settle the issues like- Political- Socio-economic- Issues between the stake holders of the system

Telemedicine Deilvery Model for Post Surgery

HomeCare

Need

Patient to bed ratio in India is very low

Patients need care even after being

discharged

Very High cost of hospitaliztion

Limitation of Enrty/Visitors to relatives

and well wishers into hospitals

Recovery is best at home-

comfort and love

RequirementsElectricity

Basic Telemedicne Equipments,VedioConf Capability,Sensors,Interface Device (mobile phone)

Communication Link:Internet/ ISDN/ Satellite

Trained Professional/Nurse,Mobile Van,Support Doc at the Hospital

Howin the Fig.

Proposed Service Delivery Model -1Telemedicine Deilvery Model for Post Surgery HomeCare

Manisha S

Limited number of Care Givers comapred to

patients

Telemedicine Deilvery Model for Post Surgery HomeCare

Manisha S

Proposed Service Delivery Model -2

This model focuses on elderly people and children.

There is a specially designed device contains some sensing mecha-nism which continuously listens to changes happening in the patients body. This device is very small and wearable so that the patient wont mind carrying it full time. We can programme the device in such a way that it sends real time medical information of the patient to the nearest hospital. Inside the hospital, they have a listening system which displays the real time status of each and every patient.

There will be some normal values set inside this device. Real time values from the patients body is compared with these normal values and when ever it crosses the limit value, the system will perform three actions simultaneously.Sends an ALERT message to the nearest hospital.Sends an ALERT signal to the Ambulance service with the patients current location.Calls one emergency number and conveys the message.

There is hardly any technology hurdles for implementing this project. The major part of the design is the multi-sensor device. The accuracy of the device is also a matter of concern.

Conclusion

Telemedicine seems to be the cheapest way to bridge the urban- rural divide in access to health care in India. Telemedicine has been successfully inplemented in many villages in India, but it is only the tip of the ice berg. India being a Hub of IT, there is very good scope for further growth

of telemedicine, with support of greater technology, standardization and regulations. Making tele-healthcare more accessible is possible only by the active involvement of all stake-

holders Government, hospitals, Technology providers, Support sta�, Educational & Research Institutes, Insurance, Financiers and Patients.

References

1. http://www.telemedindia.org/2. “Telemedicine: A New Horizon in Public Health in India”- Aparajita Dasgupta, Soumya Deb,Indian Journal of Community Medicine Vol. 33, No. 1, January 20083. “Telemedicine in India: Initiatives and Perspective”-B.S.Bedi,Senior Director,DIT, Government of India, eHealth 2003: Addressing the Digital Divide-17th Oct. 20034. “Critical Issues in Medical Education and the Implications for Telemedicine Technology” Ashok Kumar Mahapatra, Saroj Kanta Mishra, Lily Kapoor, Indra Pratap Singh - Telemedicine and e-Health. July/August 20095. “Guidelines and Standards for Telemedicine” Dr.B.S.Bedi* R.L.NMurthy 6. “Home Health Care via Telemedicine” - http://www2.telemedtoday.com/articles/humanfactors.shtml7. “Home telehealth: the future of home care” Shereene Z. Idriss Partners Telemedicine- http://www.mtbeurope.info/content/ft611003.htm8. “Mobile Telemedicine System for Home Care and Patient Monitoring”- M. V. M. Figueredo1, J. S. Dias - 0-7803-8439-3/04/$20.00©2004 IEEE9. “Mobile Telemedicine using Data Grid” -Sriram Kailasam, Santosh Kumar, and D. Janakiram10. “Current status of E-health in India” Dr. S.K.Mishra, M.S.,F.A.C.S.11. “E-medicine in India: - Hurdles and future prospects” By Gunjan Saxena and Jagannath Prakash Singh12. “Telemedicine in India: Current Scenario and the Future”- Saroj Kanta Mishra, Lily Kapoor, Indra Pratap Singh

Acknowledgements

We thank Mr. Abhay Singavi, CEO Preventive Health, Narayana Hrudhyala, for spending time with us and giving us solid ground to work on. We thank Rajen Padukone, CEO Manipal Hospitals for arranging a meeting for us. We also thank Khemchandra Birhade ( Vice-President, Business Development ) NeuroSynaptics for sharing their work process, expertise and experiences with us. We thank Mr Nandhkishore Dhomne, CIO, Manipal Hospitals, Mr. Praveen & Mr Joshy, Technical Dept , Appolo hospitals, Sister Greta & Ms Shiney, Home Care, Manipal Hospitals, and all other patients for spending time and sharing thier experience with us.

A huge thanks to Dr. Baral, Research Head, NID R & D Campus for inititating us into this project. His guidance, insights and 24x7 support was Invaluable to our research. We also thank Pradeep, KMC assistant for helping us with get articles.