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Telemedicine Case

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Telemedicine is an umbrella term which involves all the medical activity having an element of distance. Although, telemedicine has been practiced since hundreds of years by means of letters but with advancement of Information and Communication Technology, there has been a manifold increase in using telemedicine as a tool for delivering medical treatment. Telemedicine not only includes the real time consultation between patient and expert, but it also has the element of getting medical advises on prerecorded medical data such as in the case of ‘Tele-Radiology’ or ‘Tele-Pathology’ A more sophisticated model has been using it extensively for providing health care benefits to the unprivileged people. These interventions usually are taken in the form of welfare projects involving substantial investment, coordination and planning. The Government of Maharashtra launched its pilot project on Telemedicine in the year 2007, with one Specialist node at KEM Hospital, Parel, Mumbai and 5 sub district hospitals. The prime target areas for this intervention were tribal areas such as those of Sindhudurg, Nandurbar, Beed and Satara. The second phase of expansion involved participation of 5 specialist node, 23 district hospitals and 4 sub-district hospitals.

1. Telemedicine.
2. Information Technology.
3. Electronic Communication Technology.
4. Real Time Consultation.
5. Tele-Radiology.
6. Tele-Pathology.

Introduction It is essential for medical professionals to keep track and organize their patients’ medical records. Keeping this in- formation is not an easy task especially with a voluminous number of records and other documents that have to be filed, usually in rows of labeled folders in file cabinets. In the Philippines, methods in record keeping systems of medical information have not been modernized despite the developments in technology readily available in the market. The absence in automated electronic medical record keeping is apparent more particularly in the field of pediatrics. 1.1 Aim Telemedicine is composed of the Greek word τελε (tele) meaning ‘far’ or ‘at a distance’ and the word ‘medicine’. Generally, it is referred to as the use of telecommunications to provide medical information and efficiency in delivering health services to remote patients. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at facilities in two countries, using videoconferencing equipment or robotic technology. The rise in the use of mobile phones coupled with the immense developments in wireless technology has become an essential part of different domains especially in the field of medicine.

Recent mobile technologies like 3G data services can allow real-time voice and video conferencing which can provide a number of benefits in the medical field. This paved way to a new technology called Mobile Telemedicine. Developing a mobile telemedicine infrastructure could help improve the traditional record keeping system of medical professionals. The system provides efficiency in recording medical data with the use of advanced wireless technologies and web services. Portable gadgets such as PDAs, laptops and mobile phones synchronized with other peripheral attachments are utilized and connect with servers to achieve real-time communication with medical professionals. This feature becomes of circumstantial importance when emergencies and the need for immediate care and consultation arises. 1.2 Objective One sixth of humanity accounting for 1100 million people live in India. India is generally considered to be a developing country and certainly there is considerable scope for improving the per capita income and the average standard of life. India however is a paradox. We now produce and launch our own satellites. Information is being gathered regarding the feasibility of launching a HEALTHSAT – a satellite exclusively for purposes of health care.

There has been an unprecedented growth and development in Information Technology. Satellite transmission, fibre optic cables, increasing band width, fall in computer prices, licensing of private internet service providers, internet thro’ cable etc have become the buzz words even in suburban and rural India. Theoretically, it is easier to set up an excellent telecommunication infrastructure in suburban and rural India, to increase the reach of the limited number of urban specialists, than to place hundreds of specialists in places devoid of specialists. Telemedicine therefore is the answer. It is universally acknowledged that Indians have made enormous contributions in the field of information technology The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.

Literature Review 2.1 History Historically, telemedicine can be traced back to the mid to late 19th century with one of the first published accounts occurring in the early 20th century when electrocardiograph data were transmitted over telephone wires. Telemedicine, in its modern form, started in the 1960s in large part driven by the military and space technology sectors, as well as a few individuals using readily available commercial equipment Examples of early technological milestones in Telemedicine include the use of television to facilitate consultations between specialists at a psychiatric institute and general practitioners at a state mental hospital, and the provision of expert medical advice from a major teaching hospital to an airport medical centre. Recent advancements in, and increasing availability and utilization of, ICTs by the general population have been the biggest drivers of telemedicine over the past decade, rapidly creating new possibilities for health care service and delivery.

This has been true for developing countries and underserved areas of industrialized nations. The replacement of analogue forms of communication with digital methods, combined with a rapid drop in the cost of ICTs, have sparked wide interest in the application of telemedicine among health-care providers, and have enabled health care organizations to envision and implement new and more efficient ways of providing care. (e.g. digital imagery and video). 2.1.1 Evolution of Telemedicine: The idea of performing medical examinations and evaluations through the telecommunication network is not new. Shortly after the invention of the telephone, attempts were made to transmit heart and lung sounds to a trained expert who could assess the state of the organs. However, poor transmission systems made the attempts a failure. Einthoven, the father of electrocardiography, first investigated on ECG transmission over telephone lines in 1906.Telemedicine dates back to the 1920s. During this time, radios were used to link physicians standing watch at shore stations to assist ships at sea that had medical emergencies.

In 1955 the Nebraska Psychiatric Institute was one of the first to have a closed-circuit television to provide mental health services from the University’s medical center to a state hospital over 100 miles away and was later linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns. The National Aeronautics and Space Administration (NASA) played an important role in the early development of telemedicine. NASA’s efforts in telemedicine began in the early 1960s when humans began flying in space. Physiological parameters were Tele-metered from both the spacecraft and the space suits during mission. These early efforts and the enhancement in communications satellites fostered the development of telemedicine and many of the medical devices in the delivery of health care today.

In the 1970s Via ATS-6 satellites, paramedics in remote Alaskan and Canadian villages were linked with hospitals in distant towns or cities. Telemedicine’s second generation was based on the use of digital compression and transmission technologies in the late ’80s, allowing point-to-point interactive videoconferencing to and from anywhere that had access to T1, fractional T1, or ISDN lines. In May 1998, AT&T created a telemedicine network between Mount Everest and the United States Network to provide live-video telemedicine sessions from the highest point on earth. Designed and integrated by AT&T, the network will transmit status on the wellness, endurance and physiologic characteristics, such as heart rate, respiratory, circulatory and other data on climbers in the Everest Extreme Expedition. 2.2 Need for Telemedicine The people in India, particularly in rural and remote areas are found struggling to access timely medical treatment. The region of the country is characterized by densely populated communities spread over vast distances; there is a lack of qualified personnel in certain sectors of the health service.

Telemedicine has come originally to serve rural populations, or any people who are geographically dispersed, where time and the cost of travel make access to the best medical care difficult. 2.2.1 What Is Tele-Medicine? Telemedicine, a term coined in the 1970s, which literally means “healing at a distance” (1), signifies the use of ICT to improve patient outcomes by increasing access to care and medical information. Recognizing that there is no one definitive definition of telemedicine – a 2007 study found 104 peer-reviewed definitions of the word the World Health Organization has adopted the following broad description: Telemedicine may turn out to be the cheapest, as well as the fastest, way to bridge the rural–urban health divide. Taking into account India’s huge strides in the field of information and communication technology, telemedicine could help to bring specialized healthcare to the remotest corners of the country [pic] Fig 2.1 (A telemedicine program in action at the Apollo Gleneagles Hospital, Kolkata, India) 2.2.2 Impact in India With an area of about 3.2 million square kilometers, India is the seventh largest country in the world.

This vast South Asian country gifted with ancient historic background is endowed with varied landscapes like mountain regions, deserts, green plains, and the far-flung and hilly areas in the Jammu & Kashmir, Uttaranchal, North Eastern Region and the offshore islands of Andaman’s and Lakshadweep. To provide the basic minimum healthcare for India’s population which is predominantly rural and distributed across distant geographical locations has been one of the priorities of Health Administration all along. In today’s world, despite several advances made in the Medical field, the benefits are still available to the privileged few residing mainly in the urban areas. With the advent of Communication Technology, especially the Satellite Communications (SatCom) combined with Information Technology, we have means to extend the benefits from the advanced medical sciences even to the remote and inaccessible areas. It is known that 75% of the qualified doctors practice in urban centers, whereas the vast majority of India’s population lives in the rural areas.

The Indian Space Program is driven by the developmental needs of the country and has endeavored to reach out to the grassroots. Today, the national space systems comprising of advanced communication and remote sensing satellites address a variety of national needs including communications and natural resources management. Specifically in the noble context of benefiting the grassroots population, the Indian Space Research Organization (ISRO) has successfully implemented a number of projects in the areas of Drinking Water Mission, Watershed Management, Wasteland Development, Tele-education and more importantly the Telemedicine/Tele-health, which is of great social relevance to the country for enabling Specialty Healthcare to the remote, rural and underserved population. 2.2.3 Vision Telemedicine as practiced in the ICU is composed of networks of audiovisual communication and computer systems that link intensives to ICUs. These networks may be utilized as a vehicle to improve the quality, efficacy, and safety of patient care, potentially with a concomitant realization of cost savings.

They may be used to bridge time and distance barriers, giving patients in rural and underserved areas greater access to a broad range of clinical expertise through oversight of evidenced-based care utilizing multidisciplinary teams. Ideally a Tele-ICU service would be an integral component of a dedicated ICU team with co-responsibility for monitoring, oversight, and intervention. As part of the ICU team, the Tele-ICU service could facilitate the following 2.2.4 Potential barriers to Tele-Medicine diffusion Telemedicine holds great potential for reducing the variability of diagnoses as well as improving clinical management and delivery of health care services worldwide by enhancing access, quality, efficiency, and cost-effectiveness. In particular, telemedicine can aid communities traditionally underserved – those in remote or rural areas with few health services and staff because it overcomes distance and time barriers between health-care providers and patients. Further, evidence points to important socioeconomic benefits to patients, families, health practitioners and the health system, including enhanced patient-provider communication and educational opportunities Despite its promise, telemedicine applications have achieved varying levels of success.

In both industrialized and developing countries, telemedicine has yet to be consistently employed in the health care system to deliver routine services, and few pilot projects have been able to sustain themselves once initial seed funding has ended (14). Several routinely cited challenges account for the lack of longevity in many telemedicine Endeavour’s. A shortage of studies documenting economic benefits and cost-effectiveness of telemedicine applications is also a challenge. Demonstrating solid business cases to convince policy-makers to embrace and invest in telemedicine has contributed to shortcomings in infrastructure and underfunding of programs. Related to legal considerations are technological challenges. The systems being used are complex, and there is the potential for malfunction, which could trigger software or hardware failure. This could increase the morbidity or mortality of patients and the liability of health-care providers as well. In order to overcome these challenges telemedicine must be regulated by definitive and comprehensive guidelines, which are applied widely, ideally worldwide.

Concurrently, legislation governing confidentiality, privacy, access, and liability needs to be instituted. As public and private sectors engage in closer collaboration and become increasingly interdependent in e-Health applications, care must be taken to ensure that telemedicine will be deployed intelligently to maximize health services and optimal quality and guarantee that for-profit Endeavour’s do not deprive citizen access to fundamental public health services.  Fig 2.2 Showing the Hierarchy of Telemedecine Life cycle Tele Medicine Working Technical Requirements: [pic] Fig 3.1 Remote End Tech.Specifications [pic] Fig 3.2 Expert End Tech.Specifications [pic] Fig 3.3 Tele-Medicine Network 3.11MobileTelemedicine Mobile Telemedicine Unit consisting of Medical equipment along with Telemedicine hardware, software and VSAT system mounted in a Bus/Van can establish a Mobile Telemedicine centre at any place.The major areas of Mobile Telemedicine applications are in the field of Tele Opthalmology and Community Health. Under Mobile Tele Opthalmology,  Fig3.4 Mobile Telecommunication Rural Eye Camps can be conducted and the Rural Population can undergo eye screening for Cataract, Glaucoma and Diabetic Retinopathy.

Under Community Health Program, Mobile Telemedicine units are very useful not only for Disease Prevention but also for Health Promotion in terms of running awareness camps & teaching hygienic practices. 3.2. Desktop Tele-Medicine: ATNF is initiating a new concept in Telemedicine namely facilitating Telemedicine consultations wherever the consultant is. With this solution, consultants need not come to the Telemedicine room but will be connected to wherever they are, through the Internet, from any PC, where dedicated software is available.

This consultant friendly moves, is expected to considerably increase the availability of consultants for Tele-consultations. Simultaneously, it has become cost effective and relatively simple to setup new Telemedicine “Units” worldwide. This includes many convenient locations including homes. TheTelemedicine enabled Electronic Medical Record in addition to storing history, clinical findings investigations, operation notes, Medications, follow-up notes etc. will allow digital manipulation of images. Every patient using the system will have a unique ID number and hence records of multiple visits can be easily retrieved. Using this system one can keep track of all patients, who have had Tele-consultation. 3.3 Virtual Health Care @ Home Through this innovative solution, a patient can have a Tele-consultation with a specialist, from the comfort of his own home. A Telemedicine kit is taken to the Patient’s house by a member of the Telemedicine Department and connectivity established.

In addition to videoconferencing, the system enables review of all records. Peripheral medical devices from the patients end can be connected enabling the Tele-consultant to check the patients’ BP pulse rate, temperature and to listen to heart and respiratory sounds. If necessary even a 12 lead ECG can be taken at a patient’s home and evaluated by the consultant.  3.4 Pre Hospital Management It is proposed to provide Tele-monitoring and Tele-advice as part of pre hospital management on board a moving ambulance/mobile medical unit. 3.5 Domiciliary Healthcare: Pilot studies have established the efficacy of converting a home into a “Intensive Medical Care Unit”. Using dedicated Telemedicine equipments vital functions of a patient can be monitored remotely and timely advice provided. ATNF can provide these services. 3.6 Social accountability partnership pentagram [pic] Figure 3.4 shows five sectors, namely health policy, administration, academic institutions, health providers, and community. Vis-à-vis these sectors, telemedicine’s development, implementation, evaluation, and sustainability in developing countries was reviewed during a thematic review of the literature. Five key lessons were drawn from this review, which inform social accountability in health practice across the sectors; they are described below.

3.7 Social benefits of telemedicine Telemedicine has the potential to provide considerable humanitarian and development benefits by promoting access, collaboration, and resource sharing across jurisdictions. One of the documented examples of the realization of this potential, described by Wotton and colleagues, is the second-opinion consultation system operated by the Swinfen Charitable Trust. This global e-Health system has operated for altruistic, rather than commercial reasons, and also provides a context for global health professional education and evaluation. High standards of care can be maintained via telemedicine and quality of life can be improved, while sparing patients the need to travel long distances to reach hospitals or to consult physicians. Telemedicine may also provide additional levels of service to remote regions, such as elementary and secondary 3.8 The General Framework of Telemedicine Project in Maharashtra The overall network of Telemedicine in Maharashtra can be classified under two broad subheadings, viz. Specialist End Patient End Specialist End: The Specialist end consists of Five Medical colleges.

The medical colleges that have been developed as specialist end are KEM Hospital Mumbai, B. J. Medical College Pune, GMC Aurangabad, GMC Nagpur, Sir J.J. Hospital Mumbai. Nanavati Hospital at Mumbai has been made has honorary specialist centre. The J. J. Hospital at Mumbai has a dual role to play. It acts as main server centre for coordinating between the specialist centers and patient enters. Additionally, it also provides consultation service for the referred patient through teleconference. 4. Failure Analysis/ Limitation Financial barriers – Developing and implementing a tele-ICU system is a financially challenging endeavor. Costs can be broken down into four major Categories: tools, installation, training, and clinical resources. Tools include software, hardware, and equipment necessary to support the technological Infrastructure for remote assessment, monitoring, and intervention. Technical and logistical challenges – These issues can include: Complexity of initial installation and operation Lack of uniformity regarding security, privacy, and confidentiality of electronic Information Lack of high-speed connectivity and access (broadband access in rural areas) Lack of standardized healthcare information or documentation systems.

Cultural and organizational resistance – These barriers, which have been identified within healthcare by the IOM, generate walls of resistance to any type of change in patient care delivery. This has been and continues to be a struggle for healthcare institutions. Tele-ICUs are not immune to these sources of resistance. Issues related to intellectual property – Intellectual property or patents for tele-ICU services may be seen as a barrier to implementation for remote critical care services. Health systems are leery about investing millions in tele-ICU technology with overly burdensome patent restrictions that may inhibit later development. Reimbursement – A category 3 (data collection) code for tele-ICU services exists, but these costs are not reimbursed by the Centers for Medicare and Medicaid Services (CMS), making tele-ICU a value but not a profit center. All operational costs are typically funded by the hospital system utilizing the technology (typical funding for start-up is usually by grants or funded by large integrated healthcare delivery systems). Regulation – There remains ambiguity regarding physician licensing across state lines, physician credentialing and local accountability, and liability across state lines potentially involving multiple parties.

There is even lack of agreement on the optimal method for using tele-ICU, especially given the diverse nature of critical care practice models throughout the United States. 5. Application 5.1 Rural Health One of the greatest challenges in rural health is assuring that medical expertise is available where it is needed, when it is needed. This is difficult for remote rural healthcare facilities because they are often unable to attract, afford or retain specialty providers. Telemedicine helps solve these issues by allowing access to specialists regardless of location. This is done with live video or store and forward solutions or combinations of both. With telemedicine, a remote physician “sees” the patient remotely using communications technology and special medical devices. The specialist can examine the patient, review vital signs and patient’s history, provide assessment, diagnosis and treatment. Usually treatment can be delivered locally. This minimizes or eliminates the need for travel for either the patient or the specialist. Telemedicine also helps rural facilities to train and retain clinicians because telemedicine allows on-the-job experience and remote participation in grand rounds. 5.2 Developing Countries Telemedicine allows rapid deployment of healthcare to a developing population though relatively low cost clinics.

Rather than build and staff large numbers of sophisticated facilities, telemedicine allows basic clinics to share the expertise of clinicians and clinical specialist who may be located centrally or decentralized. Expertise is delivered where it is needed and when it is needed. This substantially changes the healthcare delivery strategy of a developing country. It accelerates deployment and costs a fraction of a traditional “bricks and mortar” strategy. 5.3 Corrections Telemedicine allow prison facilities to deliver high quality care without the cost and dangers of inmate transportation or the need for clinical specialist to enter the facility. Telemedicine substantially improves access to care while substantially reducing costs. Telemedicine has proven effective for clinical as well as mental health. Corrections facilities in many states, the US federal prison system as well as prisons outside the US have implemented telemedicine for healthcare delivery to their inmates.

They have realized substantial cost savings and found that telemedicine is safe and effective and inmate acceptance is very high. 5.4 Schools Telemedicine provides support to the school nurse and allows her or his access to expert medical opinion on when it is needed. The school nurse is an isolated provider yet she has to respond to a variety of needs. In some rural communities, the school nurse may be the only healthcare provider. If she cannot confidently diagnose and treat an issue, the student must be referred many miles away. Telemedicine
addresses these issues specifically. 5.5 Mobile Health Telemedicine allows mobile health unit access to specialist expertise regardless of where either the mobile health unit or the specialist is located. Mobile health units can serve the community send challenging cases or second opinion requests to a remote specialist for x-ray reads, diagnosis support, treatment advice, etc. to assure the local patient receives appropriate care. 5.6 Disaster Relief The benefits for Disaster Relief are similar to rural health and mobile health. Telemedicine allows healthcare delivery capability to move in quickly after a disaster. This allows the on-sight providers rapid access to advanced expertise and capabilities for triage and care electronically when and where it is most needed.

5.7 Shipping and Transportation Whether it includes crews of cargo ships at sea, guest and crews of cruise ships, passengers and crews in the air or owners, guests and crews on private yachts. Telemedicine allows access to advance healthcare expertise, triage advise as well as diagnosis and treatment regardless of where the ship or plane. Telemedicine avoids the high cost evacuations and unscheduled diversions. 5.8 Industrial Health Industrial sites such as mines, drilling platforms or industrial campuses depend on the health of their employees to operate. They must respond to an unpredictable set of health needs to support sometimes hundreds of employees. Telemedicine avoids the high cost evacuations and assures that the worker receives appropriate treatment and is available to support operations as soon as possible.  5.9 Key Points Tele-Medicine policy or strategy. Only 20% of responding countries reported having fully implemented or begun implementation of a national telemedicine policy or strategy. Developed countries are more likely than developing countries to have, or to have begun Implementing a national telemedicine policy or strategy; however, significant growth in this area is forecast for developing countries.

The African, Eastern Mediterranean, and South-East Asian Regions currently show the lowest rates of national telemedicine policy implementation, but the highest projected growth. These regions may require extra support in the development of telemedicine policies and strategies in the near future. 6. Future Scope ISRO’s Telemedicine Project is gaining more acceptability and has potential to open up new frontiers for the rural health care in India. Some States have come forward to introduce Telemedicine in an operational mode and have prepared the District Hospitals with Telemedicine facility both for Ambulatory & Intensive care for cardiac related treatment. States of Karnataka, Kerala and Chhattisgarh have initiated the establishment of SatCom Based Telemedicine facility in all their district hospitals which will be connected to different Speciality Hospitals in the major cities. This will soon be followed by other states too. With the steady growth of Telemedicine application, it is also envisaged to develop an exclusive “HEALTHSA T” for meeting the health care needs of the country at large. Research and develop TRAIN (Tele-ICU Research Awareness Implementation Network)

1. Internet-based resource site 2. Educational program 3. Teams to assist in education and implementation of tele-ICU initiatives 4. Networking platform 5. Research initiatives and support 6. Support for congressional bills to elevate the focus on critical care services and to expand the critical care workforce Conclusion This report provides a snapshot of the Federal government’s activities in the area of telemedicine. Telemedicine, in one form or another, has actually been practiced for over thirty years. At the most simple level, a nurse providing clinical advice over the telephone is telemedicine.

The focus of the most recent activity, however, has been on telemedicine applications that generally employ advanced image as well as audio capabilities. These technologies can range from high resolution still images (e.g., x-rays) to sophisticated interactive teleconferencing systems. Although interest and investment in these advanced systems is rapidly growing, significant skepticism about telemedicine remains. This skepticism is fueled by concerns about the current low use of telemedicine systems and about continued sustainability once Federal, state, or private subsidies disappear. At the heart of much of this concern is uncertainty as to what the Federal government might do or not do to advance telemedicine.


[1] (2003, Mar.) Telemedicine makes its debut in India. [Online]. Available: http://newsarchives.indiainfo.com/2000/04/12/tele.html [2] “ISRO—Apollo pilot telemedicine project in India, Space technology applications—Satellite communications applications,” United Nations, http://www.unescap.org/icstd/space/documents/telehealth/isro.htm., 2001.
[3] K. Ganapathy. (2002, Dec.) Telemedicine in India—The Apollo experience. [Online]. Available: http://www.thamburaj.com/telemedicine.htm [4] S. Salam. (2002, Jun.) Telemedicine: Hype vs. reality. Express Healthcare Management [Online]. Available: http://www.expresshealthcaremgmt.com/20020 630/medtech1.shtml [5] (2003) TeleMedicineVision. [Online]. Available: http://apollohospitalgroup.com/vision.htm [6] Gundy BL, Jones PK, Lovitt A Telemedicine in critical care: problems in design, implementation, and assessment. Crit Care Med. 1982;10:471-475.

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