May 2007

Indias Tryst with Telemedicine : Jagjit Singh Bhatia, Mandeep Kaur Randhawa, Harpreet Kaur Khurana, Sagri Sharma

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Telemedicine can bridge the existing divide in terms of healthcare between the urban and rural India. Thankfully, today telemedicine has become increasingly possible due to  a confluence of ongoing technical advances in multimedia, imaging, computers and information systems, as well as in telecommunications. Telemedicine would enable the population of remote and rural India to avail the facilities and expertise of  big super-specialty hospitals in the metros. The timely diagnosis and advise by specialists would in many cases avoid the aggravation of conditions of patients, thereby saving the lives, money and  time. Succinctly, the advantages that telemedicine can accrue for the population can be manifolds.

Telemedicine, as the name suggests, is the application of communication and information technology for remote consultation and diagnosis of diseases by medical professionals. It is a procedure through which medical services are made available remotely, through a combination of telecommunications, multimedia technologies and medical expertise. India is one of the largest producers of doctors and nurses in the world, and is not far behind in terms of providing science and technology support, required for successfully setting up the stage for telemedicine in India.

Telemedicine is the hope for a common villager for a better access to healthcare. Now it is the duty of the medical professionals, engineers and technologists to spread the awareness among the general population and make this promising venture a success in India. Here we will discuss how telemedicine adoption can help to improve the healthcare conditions of rural and remote population in India and how Center for Development of Advanced Computing (C-DAC) is contributing in  telemedicine field.

The Indian scenario

Being heralded as one of the several possible solutions to some of the medical dilemmas  facing many developing countries,  telemedicine has already brought a plethora of benefits to the populace of India, especially those living in the rural and remote areas (constituting about 70 percent of India’s population). One of the many reasons for the huge potential of telemedicine in India is because  a large chunk of India’s rural population doesn’t have access(or have very limited access) to even primary healthcare facilities.

We should accept the fact that India has a large population and providing quality healthcare to such a large population is not an easy task. The lack of funds is a major hindrance towards setting up of as many medical facilities as are needed. Specialists are stationed at these limited medical facilities, and patients have to travel to these centers, even to simply get diagnosed. The alternative being that of specialist making periodic visits to the patient. Such approaches are implemented in various rural and other parts of India with mobile clinics, mobile specialty hospitals, etc. However, the response time in either case is generally high. Moreover, in some challenging cases, often doctors and specialists need to consult other specialists to ensure that all aspects of a complication or patient disorder have been taken into consideration.

Besides wastage of precious time(in case of some critical illness every minute can be precious) in commuting to the health centers from remote areas, other important dimension is the financial implication of making visits to a health center or the patient site for a diagnosis. The associated costs of travelling, staying, equipment movement, etc. are high. If the patient  has to travel to the referral facility, not only will it cause him discomfort (the situation is much worse in case the patient is under trauma), it will also cost him time and lots of money.

If the specialist has to travel to the site (which is not generally done), then the cost is much more, as his time is very valuable not only in terms of money, but also because other patients will be deprived of his services while he is travelling.

In such a scenario, which is very much prent in India, telemedicine can emerge as a welcome alternative to supplement conventional healthcare. One of the biggest benefits telemedicine provides is the death of distance. Deploying it can reduce unnecessary travel, expense and even strain. Once the virtual presence of a specialist is acknowledged, a patient can access medical resources without the constraints of distance. It also solves the problem of retaining specialists in non-urban areas.

Moreover in our country, where a large population lives in rural and semi-urban areas, the telemedicine holds a great promise for the masses at large, as the hospitals and the health centres located in these areas are in general ill-equipped in terms of medical expertise or the diagnostic equipments. According to the available healthcare statistics, about 75 percent of the qualified doctors in India practice in urban areas, and 23 percent in semi-urban areas, so this leaves only 2 percent of the doctors to cater to the health needs of a whopping 70 percent of the Indian population, living in villages. The most unfortunate outcome of this distribution is that 80 percent of the medical facilities in India are being channelised to the urban areas and a meager 20 percent comes to the rural areas. In such an otherwise depressing scenario, telemedicine has the promise to revolutionize this lopsided delivery of healthcare in India.

Telemedicine can bridge the existing divide in terms of healthcare between the urban and rural India. Thankfully, today telemedicine has become increasingly possible due to  a confluence of ongoing technical advances in multimedia, imaging, computers and information systems, as well as in telecommunications. Telemedicine would enable the population of remote and rural India to avail the facilities and expertise of  big super-specialty hospitals in the metros. The timely diagnosis and advise by specialists would in many cases avoid the aggravation of conditions of patients, thereby saving the lives, money and  time. Succinctly, the advantages that telemedicine can accrue for the population can be manifolds. They include timely availability of expert medical services and opinion at affordable cost,  thereby preventing the aggravation of illness and disease among the patients,maintenance of database with respect to various diseases and locations, and remote training of medical students by experts in the field.

One of the biggest benefits telemedicine provides is the death of distance. Deploying it can reduce unnecessary travel, expense and even strain. Once the virtual presence of a specialist is acknowledged, a patient can access medical resources without the constraints of distance. It also solves the problem of retaining specialists in non-urban areas.

Telemedicine has added a new dimension in modern clinical practice of medicine in western countries where it is now a matter of routine. In western countries, telemedicine is now being utilized as an advanced facility for providing specialty services for hospitals and medical centers where experts are not readily available, thus eliminating the impediments of time and distance. However clinical practice with modern technology is an expensive proposition and needs highly experienced experts in interpreting the imaging technology.

Moreover, in India the patients at small hospitals including the hospitals in medical colleges are not given the facilities of expert opinion in the clinical practice through usage of modern technology in diagnosis and treatment.  Thus the best way and perhaps the most economical method of  extending telemedicine facilities in India is through referral centers. The referral centers should be equipped with all the necessary equipments and should be directly connected via satellite to the user-hospital/institution. Here it deserves a mention that C-DAC initiated the program of development of telemedicine technology in India,  way back in 1999, with an aim of demonstrating and uating its feasibility in the Indian context.

Timely help during mega events and disasters

Telemedicine services can also  be of   great aid during times of crises or disasters, such as earthquakes, devastating fires, and other natural disasters, to provide backup services. Some recent events in India point to  telemedicine’s role in tackling unforeseen disasters. On 26 January  2001, due to the devastating earthquake in Gujarat, some 40,000 lives were lost, and over one lakh people were badly injured. The need at that point of time was to immediately treat the injured and provide healthcare facilities to prevent further deaths. The earthquake also decimated many hospitals and other medical facilities. In this gloomy scenario the promising technology of telemedicine made its presence felt.

The day after the earthquake, the Ahmedabad-based Online Telemedicine Research Institute (OTRI) came to the rescue and established the first communication link from Bhuj, which was close to the epicenter of the quake. Specialists were able to provide consultations from far-off places, thanks to the established telemedicine links. For example, after the telemedicine center was set up at Bhuj hospital, an X-ray facility was provided to the people, whereby a specialist provided online consultation from Ahmedabad. During the subsequent days, quake victims could get medical advice from other doctors, based at Ahmedabad and Bangalore. Over 750 sessions were conducted in a period of 30 days, thus saving many lives.

Apart from Gujarat, there are a couple of other cases that show the potential of the technology. For example, during the last Kumbh Mela, which drew over 25 million pilgrims to the banks of the Ganga for the holy dip, telemedicine was deployed successfully. OTRI, together with a team of tech-savvy doctors, transferred data of over 200 ailing pilgrims, besides sending microscopic images of microorganisms, in order to monitor the levels of cholera-causing bacteria  in the river. Another pertinent example is the Asia Heart Foundation that has been successfully practicing telecardiology between Bangalore and the cities in eastern India.

C-DAC’s Initiatives

Centre for Development of Advanced Computing (C-DAC), Mohali, formerly known as Centre of Electronics Design and Technology of India (CEDTI), is a premier institute of the Ministry of Communications & Information Technology, Govt. of India, involved in R&D, design, development and deployment of advanced information technology products and solutions. The centre also specializes in embedded & VLSI technology, bio-medical, electronics, telemedicine  and  entrepreneurship development. We, at Centre for Development of Advance Computing, are working in the field of telemedicine since 1999, and have successfully developed state-of-the-art telemedicine application packages namely, ‘Sanjeevani’ and ‘e-Sanjeevani.’

We have, as a pilot project, established telemedicine technology at six major locations in India. These locations were subsequently connected to nearby districts and primary health centers to make a telemedicine hub. Our first endeavour was on establishing telemedicine sites at All India Institute of Medical Sciences, New Delhi, Post Graduate Institute of Medical Education and Research, Chandigarh and SGPGIMS, Lucknow. We have expanded it in the second phase to connect three more medical colleges namely, Indira Gandhi Medical College, Shimla, Medical College, Rohtak and Medical College, Cuttack. The telemedicine software package was developed in-house, under the expert guidance of the doctors in these hospitals.

A pilot project on ‘Development of Telemedicine Technology and its Implementation’ was approved for implementation by the Department of Information Technology, Ministry of Communications and Information Technology, Govt. of India and it has been implemented over the  ‘telemedicine network’ connecting PGIMER, Chandigarh, SGPGIMS, Lucknow and AIIMS, New Delhi on ISDN lines.

The objectives of this pilot project are outlined below:

To run and implement successfully the telemedicine technology over the telemedicine network, connecting the three locations at PGIMER, Chandigarh, AIIMS, New Delhi and SGPGIMS, Lucknow.

To establish a dedicated satellite communication facility using very small aperture terminal and thereby networking medical centers in northern part of peninsular India.

To establish a telecommunication technology network, which can provide a comprehensive range of high-quality health services to rural and remote areas in India.

To purchase cost-effective hardware needed for transmitting data and images of adequate diagnostic quality.

To enable well-established image & data archiving, printing for graphics, images and video data.

To train the doctors and patients to use the telemedicine technologies effectively and optimally, with a view to develop their faith and confidence in these technologies.

Documenting the technology and extending it to specialty centers within India and worldwide.

Our subsequent effort was on establishing telemedicine sites at different locations in the state of Himachal Pradesh, which is a remote and hilly state of India. C-DAC is further working on implementation of telemedicine technology in rural areas of Punjab, and in Chandigarh.

(i) Telemedicine in Himachal Pradesh

The project envisages the customized development of telemedicine application titled ‘Sanjeevani’ and its subsequent deployment in the rural areas. ‘Sanjeevani’ is an integrated telemedicine solution based on ‘Store & Forward’ concept of telemedicine.

As many as 24 locations have been identified for deployment of the project. These range from community/ primary centres to civil / regional hospitals and IGMC, Shimla. The telemedicine application will comprise the basic tele-radiology, tele-pathology and tele-cardiology modules. This telemedicine application will deliver specialized healthcare to the patients of underserved rural areas of Himachal Pradesh, at very low cost.

At present, the position of healthcare in these rural areas is not good. The number of primary healthcare centers in the state of Himachal Pradesh is less and most of the vital medical infrastructure are not in proximity to the section of its population.  In the rural areas of Himachal there is a high prence of untreated curable diseases, which remains untreated due to lack of resources. The application will enable the provision of specialized medical care, services and treatment to the patients in the far flung, remote and inaccessible areas of Himachal Pradesh. They live far from the specialty hospitals, to where it is difficult for these rural patients to commute.

The objectives of the project are as follows:

To develop a customized telemedicine application in the rural and remote areas of Himachal Pradesh for providing specialized medical care and support to the patients at their convenience, and at an affordable cost. This will involve connecting the community health centers/primary health centers and block level/district level hospitals in the rural areas to IGMC, Shimla for expert advice. As many as 14 such centers / hospitals are being connected in Phase I and rest in Phase II. The connectivity will be further extended to PGIMER,Chandigarh over the existing telemedicine linkage.

To establish seamless connectivity over diverse communication environment in the state.

To develop software interfaces with low cost medical diagnostic equipment so as to offer a very low cost telemedicine solution for rural areas.

To introduce new software/hardware features in the existing telemedicine technology for developments not covered already.

To give a boost to the production of low cost medical diagnostic equipments for telemedicine technologies in India.

To spread medical education among the medical profes
sionals for their continuous upgradation at a very low cost, even to far off places in rural areas.

To develop it as a pilot project for subsequent implementation all over India.

Telemedicine set up implementation at various health institutions in Himachal Pradesh will be based on the network that can be classified into the following categories:

Phase I: Installation of the identified equipment and to link two medical colleges in the state;

Phase II: Linking with all the identified hospitals;

Phase III: Integration with Hospital Information System (HIS).

Implementation of telemedicine application software ‘Sanjeevani’ in Himachal Pradesh will be  providing benefits to the population in the following ways:

A best possible healthcare facility will be available to all of them.

They need not move the patient to specialty hospital at far away places unnecessarily.

Since majority of the potential  population for this telemedicine application earns their livelihood through daily wages,  they will not only be saving time, but also their hard-earned money, if they avail of this facility.

The cost involved in the treatment using telemedicine technology shall definitely be manifold less than the healthcare cost now being borne by this population.

(ii) Telemedicine in Punjab

The aim of this C-DAC project is to deploy the customized telemedicine application at a wider network, covering the rural areas of Punjab. The application will enable the provision of specialized medical care, services and treatment to the patients in the far flung, remote and inaccessible areas of Punjab, from where it is extremely difficult for the patients and their families to commute to specialty hospitals.

The browser-based telemedicine application named ‘e-Sanjeevani’ is an outcome of the advancement over the existing desktop application ‘Sanjeevani’. This telemedicine application will deliver  specialized healthcare to the patients of underserved rural areas of Punjab at very low cost. This package has been lab tested on LAN (10/100 Mbps) and is running on a public website named http://www.esanjeevani.in/

The main outcome of the project is to deploy ‘e-Sanjeevani’ in all the districts of Punjab but the intermediate output is to deploy and test it at as many as 20 locations, which have been identified with Punjab Health Systems Corporation Punjab.Deployment of ‘e-Sanjeevani’ will help the poor and needy sitting at remote and urban places where specialized treatment is not available. With this, the poor can easily have the advice of the specialists and suffer less. Hereby the deployment of this project by C-DAC, Mohali will effectively help the underserved and underprivileged community of Punjab. 

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