April 2009

Appraising Telemedicine Case studies Lessons and Challenges : Lieutenant Colonel Salil Garg Cardiologist, Command Hospital, Pune and Squadron Leader Mudit Mathur, DD Space Ops, DSCC, Bhopal

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Time goes, you say? Ah, no! Alas, time stays, we go � Henry Austin Dobson

On October 25th, 1965, downtown St. Louis stopped in its tracks and thousands watched as the last piece of the mammoth gateway arch was being put into place. Weight of the two sides required braces to prevent them from falling against each other. Fire hoses poured water down the sides to keep the stainless steel cool, which kept the metal from expanding as the sun rose higher. Some horizontal adjustments were required, but when the last piece was put into place and the braces released, it fitted perfectly, according to plan, and no one was surprised (Liggett, 1998). Although, the last and most visible span that connected the two halves received the maximum attention of onlookers, but success was actually related to how the original supports were positioned. ,

Just like the arch, telemedicine requires a careful process that includes systematic design and implementation. There will be success if all pieces of the plan receive the same attention as the most obvious.

Developing countries face various problems in the provision of medical service and health-care, including funds, expertise, resources, shortage of doctors and healthcare professionals. Widespread use of telemedicine services could allow universal health access. Telemedicine offers a range of solutions covering emergency medical assistance, long-distance consultation, administration, logistics, supervision, quality assurance, and continuous medical education and training… In developed countries, there has also been a growing interest in telehealth as a means to ease the pressure of healthcare on national budgets.  Telecom and healthcare ” providers can achieve synergies in order to deliver such services.

The future has a way of arriving unannounced – George Will

Indian Case

A number of initiatives are underway in the area of telemedicine in India.  The primary objective is to provide quality consultation and caring for patients in areas where specialised patient care is not available. Although, telemedicine implementation remains in its infancy, interest and activity appears to be growing to provide consultation of a super-specialty doctor from a distance through videoconferencing along with exchange of medical records online. In addition to major support and thrust provided by Department of IT (under Ministry of Communications & IT, Govt. of India) through projects and systems, organisations like ISRO, reputed academic medical institutions like SGPGI, AIIMS, PGIMER, AIMS, SRMC and corporate hospitals like Asia Heart Foundation, Apollo Hospitals, SGRH, Fortis, Max etc. have taken and are continuing to take significant initiatives for installation of telemedicine systems at different parts of the country.

The Department of IT (DIT) has taken a pivotal role in defining and shaping the future of telemedicine application in India. DIT has been involved at multiple levels � from initiation of pilot schemes to standardisation of telemedicine in the country. It has funded development of telemedicine software systems – the prominent ones being Mercury and Sanjeevani software by C-DAC. DIT has also sponsored the telemedicine project connecting three premier medical institutions – viz. SGPGI-Lucknow, AIIMS-New Delhi and PGIMER-Chandigarh – using ISDN connectivity. These hospitals are in turn connected to other state level hospitals. In West Bengal, DIT has implemented telemedicine for diagnosis & monitoring of tropical diseases using low speed WAN, developed by Webel, IIT-Kharagpur and School of Tropical Medicine, Kolkata. The system has been installed in School of Tropical Medicine, Kolkata and two district hospitals.

DIT has also funded establishment of an Oncology Network for providing Telemedicine services in cancer detection, treatment, pain relief, patient follow-up and continuity of care in peripheral hospitals (nodal centers) of Regional Cancer Centers (RCC). The project was implemented by C-DAC and RCC-Trivandrum. The Kerala OncoNET model has been replicated by DIT at RCC-Adiyar in Chennai with C-DAC’s Mercury Telemedicine Solution. Success of the cancer network in Kerala has encouraged the Ministry of Health & Family Welfare, Government of India to take major step towards launching National Cancer Care Network. Several state level telemedicine networks like Kerala state Telemedicine Network, Tamilnadu state Telemedicine Network, Haryana & Punjab state Telemedicine Network, etc. are coming up as pilot projects and have shown promising results. In addition, three state capitals in north eastern states of India are getting connected with super- specialty hospitals – one at Kohima, Nagaland is already operational. Another initiative linking one state level hospital each in Sikkim and Mizoram, with Indraprastha Apollo Hospital in New Delhi is an example of Public-Private Telemedicine Network that is in place and under effective use.

In a short span of time, some progress has already been achieved in the field of telemedicine in India. However, there is still a long way to go. While there are over 20,000 PHC’s providing primary care services in rural areas, and about 500 district hospitals, telemedicine has reached only about 100 centers  with 50% of them in urban centers. If we were to look at a five-year horizon for telemedicine in India, efforts would be considered successful only if we have telemedicine reaching out to at least all district and taluka level hospitals throughout the country. But for this to be a reality, we need a major thrust from the government and private sector and help from International agencies.

In a short span of time, some progress has already been achieved in the field of telemedicine in India. However, there is still a long way to go.

One of the key factors for success of telemedicine in India is going to be the reliability of telecommunication link. In this context, the ISRO Chairman has committed to provide free bandwidth for the purpose of telemedicine and tele-education. ISRO has been deploying satellite based telemedicine nodes in collaboration with state governments and has so far deployed around 250 nodes across the country. Ministry of Health and Family Welfare has set up a National Task Force to address various issues to promote telemedicine in the country and has launched a major country wide network of district hospitals and medical colleges under the Integrated Disease Surveillance Project. In addition, National Cancer Care Network and Medical College network are going to be implemented in the near future. Need for an over arching architecture/framework for the country covering 3 levels, namely, PHCs, district hospitals and referral/super-specialty hospitals and also covering hardware/software requirements, bandwidth and connectivity issues has been felt. This paves the way for introduction of integrated telemedicine network in India.  Fiber optic network of government and private telecommunication service providers are resulting in availability of high bandwidth terrestrial connectivity to build ubiquitous telemedicine network across the country wide at competitive price.

Any change, even a change for the better, is always accompanied by drawbacks and discomforts – Arnold Bennett

CASE STUDIES

Case1:  A young physician posted at a zonal hospital in a remote location. was called one night to attend an ailing family who has come from a remote village in the mountains after traveling close to 24 hours. Three members of the family are already dead after consuming a wild variety of mushroom.  and rest of the four are extremely sick. Being an exotic form of poisoning not much information is available in standard textbooks. No expert on mushroom poisoning or mushrooms is available. The last time anyone has seen mushroom poisoning  was in 1966, and the experienced and benign doctor does not remember much of the treatment. Internet connectivity is still poor, the speed is slow and marred by frequent electricity cuts and unavailability inside the hospital campus. The nearest internet caf� is 4 to 5 kms away. The doctor loses another patient by morning. He rings up his brother in Bangalore who does an internet search for him and gives him the basics of the treatment. He is not a doctor but a software engineer and dictates the basics and management and of mushroom poisoning on the telephone. After this, he gathers all the information and and sends an entire set of printed documents by speed post. It reaches the doctor by next morning. By that time, the other three are critically ill but still on the road to recovery as most of the treatment has already been initiated. Fortunately, they survived. However, there is an epidemic of mushroom poisoning in the region and few people do die, due to lack of dissemination of information.

Case2: The year is 2009 and there are two sets of patients in two different settings. One is a businessman in one of the satellite towns of Delhi, who complains of severe retrosternal chest pain. He is suspected of having a heart attack and calls for an ambulance from one of the large corporate hospitals. The ambulance is equipped with a telemedicine portal and an urgent ECG is taken which confirms the diagnosis. The ECG is transmitted to a  cardiologist in real time on his mobile and he plans further management. The nearest  catheterization laboratory is located and the estimated door to balloon time calculated. It is estimated to be more than 90 min and the patient is offered chemical fibrinolysis and taken up for an angioplasty later on. Two days later, he walks out of the Hospital, ready to work, with his myocardium saved, two intracoronary stents in place and few chances of being a chronic heart failure patient, in view of the myocardium saved.

The other is a middle-aged labourer in the backwaters of Maharashtra, who presents with chest pain during the night. There is no transport, and for two to three hours he is treated locally as a case of acute gastritis in the hope that the pain would subside. As the patient continues to be symptomatic, he is shifted to a PHC, where the paramedical staff suspects him of having a heart attack. He is immediately transferred to a district level hospital, but he dies enroute. With him dies hopes and aspirations of a seven member family that he left behind.

Case 3: Circa 2025. Rahul is manning a space station orbiting around the Mars. He is already a hundred and one years old. He has already undergone lens replacement in both eyes, restructuring of all teeth by orthodontists, a pacemaker implantation, multiple bio-absorbable stents in his coronaries and replacement of the lower spines, hip joints and knees with prosthesis and multiple skin management programs. The joints were titanium and had been covered with biomaterial that was very much akin to skin but more resilient and replaceable, all carried out by robotic surgeons and controlled by surgeons posted millions of kilometers away. He looks 35 years old. Previously, he had hypertension, which was now adequately controlled with a drug given once every five years and has had a pancreatic transplant that had cured his diabetes. He is still considered to be a high risk for stroke and a myocardial infarction which could not be modified completely even with gene therapy. When he suddenly had blurring of eyesight and weakness of the left side of the body the monitors in the spacecraft detected the change in parameters and ordered a full radiology scan in situ. The results were transmitted to the nearest doctor who was at that time orbiting Jupiter and a clot bursting drug immediately injected. Rahul survives and he does not have any residual impairment. Drugs were stocked in the spaceship on the basis of a pre operational mathematical probability. There has been a major debate for the last few years regarding the necessity for taking the concurrence of human doctors at all prior to medical management with a set of activists actually legislating to do away with doctors absolutely.

All the three case studies given above have been taken from real life. The first incident actually happened; the second case study is an everyday occurrence all over the world many times over. The third case scenario is just an imaginary glimpse of the future and maybe here before we actually expect it.

I used to think that cyberspace was fifty years away. What I thought was fifty years away, was only ten years away. And what I thought was ten years away… it was already here. I just wasn’t aware of it yet. – Bruce Sterling

Problem

Telemedicine applications

  • There is a severe shortage of healthcare professionals.
  •  Lack of competent medical specialists using state-of-the-art medical technology and other sophisticated diagnostic equipments.
  •  Lack of medical specialists and difficulties to obtain consultations between doctors in regional and remote hospitals with those in referral hospitals.
  •  The population living in rural and remote areas suffers from lack of healthcare.
  • Telemedicine links between hospitals and other medical institutions for improving healthcare services by centralisation and coordination of resources (specialists, hardware and software packages).
  • Deployment of fixed or mobile telecentres, to bring telemedicine services to rural areas.
  •  Mobile telemetry service in remote areas using a small bus equipped with appropriate medical diagnostic equipments, a mobile satellite phone and a doctor. 
  • High maternal and perinatal mortality rate.
  •  Need to improve maternal and child care.
  •  I Inadequacy of trained staff and very late identification of pathological pregnancies.
  • The maternity units in any region could be connected by a telemedicine link to the maternity service in a large regional hospital or to a referral hospital. 
  • Very few doctors (particularly in rural and remote areas) have access to medical journals after graduation.
  •  Need for continued medical education accessible to as many health professionals as possible.
  •  Poor internal telephone system in most hospitals. 
  • E-mail and Internet access for regional and rural healthcare centres and small hospitals.
  • Connecting as many hospitals and healthcare centres as possible to a medical information system to derive benefits such as:
  •  improved standard of medical practice
  • Improved epidemiological and other reporting�
  •  continuous education for doctors and medical staff outside urban areas
  •  access to several worldwide medical databases through Internet.
  • Modernisation of internal communication systems of hospitals for improving efficiency in healthcare delivery and providing a basis for introduction of telemedicine services.

Medical Approach

Let us summarize the results and findings of telemedicine missions.  What are the common and most urgent problems in developing countries which could be alleviated by using telemedicine? (Table:1)

Legal and Safety Issues

Medico legal aspects of telemedicine are beginning to take a centre stage. Confidentiality in the transfer of electronic medical record is of prime concern. There is a debate on adequacy and accuracy of electronically transmitted data for establishing a correct diagnosis. Suppose, if due to technical malfunction, a patient’s data is not transferred correctly (e.g. image degradation in an echocardiogram or in a histopathology slide) it will alter the diagnosis. In this case, who will be held responsible – the attending physician? the hospital? the manufacturer/distributor of the equipment? or the telecom provider? ATEL uses software that captures post consultancy details and authenticity of data is maintained through e-signature of doctors. Should there also be an acceptance from the patient’s side regarding limitations of technology. After all, caregivers are trying to do their best, with no wrong intentions.

STOPPING POINT

“�Ever since my eye swelled up, I’ve gone to church three times a week to pray for a cure.  As soon as I’m better I’m going back to thank God.  I always knew He would send a way to make me better – I just didn’t know that it was going to be from London�” says Anna Mobutsu, a 23-year-old farm labourer, who cannot imagine taking a journey farther than a few hours’ bus ride from her home in the small African town of Nelspruit. As an illiterate single parent with a seven-year-old son and an elderly mother to support, Anna does not even have a television to introduce her to a world beyond her own.  “�But this afternoon I went to London.”

(The statement above is just one of many success stories on the adoption of Telemedicine in Africa).

Telemedicine will continue to be a growing influence on the profession of medicine. The benefits of this innovation will be in two primary areas � medical benefits and cost benefits. First, telemedicine is a logical extension of the growth of the technical and technological aspects of health care. The medical benefits of an active telemedicine program are related to how professionals use the technology. Second, cost effectiveness is likely to be the most significant outcome of telemedicine. There will be substantial cost advantages for organisations that understand and utilise technologies effectively. Certainly, telemedicine is only one category of technology, but it may soon be the ‘ears and eyes’ of healthcare organisations. Dr Devi Shetty recently wrote in the Indian Heart Journal, “We have been running a chain of coronary care units and telemedicine centers in remote parts of the world and have treated over 22,000 heart patients in last 5 years. We use very basic technologies, and have realised that what makes the difference is people behind the services and not the technology they can use.”5

Every great advance in science has issued from a new audacity of imagination – John Dewey

This work provides the overview of the field of Telemedicine practices done by various experts and institutes. Author(s) take no claim in either designing the models or its concepts, however, direct integration of isolated work in the field of Telemedicine practices has been done in this article. Suitable cross references are marked.

References:

a) Clark, R. (1983). Reconsidering research on learning from media. Review of Educational Research, 53(4), 445-459.
b) Grigsby, J. & Sanders, J. (1998). Telemedicine: Where it is and where it is going. Annals of Internal Medicine, 129 (2), 123-127.
c) Kvedar, J., Menn, E., & Loughlin, K. (1998). Telemedicine: Present applications and future prospects. Urologic Clinics of North America, 25(1), 137-149.
d) Liggett, R. (1998). A prescription for telemedicine. Telemedicine Today, October, 2.
e) Simonson, M., Schlosser, C. & Hanson, D. (1999). Theory and distance Education: A new discussion. The American Journal of Distance Education, 13 (1), 60-75.

  • Michael Simonson, Program Professor, Instructional Technology and Distance Education
  • ‘National Rural Telemedicine Network Suggested Architecture and Guidelines’ ;Draft Proposal Version 1.0 ; Ministry of Health & Family Welfare, Government of India
  • Fenster,P.  (2000). TeleMedicine.  The Times, South Africa, Tuesday 14th March 2000
  • Telemedicine Indian Heart J. 2006 Nov-Dec;58(6)383.

 

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