Februaury 2009

Telemedicine Myths & Realities : Lieutenant Colonel Salil Garg, Cardiologist, Command Hospital, Pune and Squadron Leader Mudit Mathur, DD Space Ops, DSCC, Bhopal

The armed forces have forever been the hub of innovation and also consistently been early adopters of innovative technology from various fields. Some of the finest doctors and surgeons serve in this honourable vocation. They are also one’s to face the most difficult and trying of situations, where they must explore all possible tools to function efficiently. The following article will give more insight into the same.

“It’s not enough that we do our best; sometimes we have to do what is required.” Winston Churchill

Recent developments in computing and networking have enabled collaborative biomedical engineering research by geographically separated participants. One of the other most promising aspects of these technologies is to use them to extend the human intellectual capabilities for medical decision-making. Since these technologies can make the expert’s information available at any location, the emerging technologies are poised to drastically reduce healthcare cost and provide medicare service including diagnostic capabilities in remote locations. The medical services using the tools of information technology are now grouped under a new discipline called telemedicine. Telemedicine consists of various medical services where patients can be examined, monitored and treated, even while the patients and doctors are located in different places using Information Technology i.e. computer and telecommunication technology (Samaddar & Samaddar, 2003). Patient’s records can be sent via text, voice, images or even video and medical advice offered from a remote location on Internet or off-line as digital content. We have to realise that Doctors are becoming increasingly expensive and if telemedicine is used judiciously, it may help in rationalising medical care.

This series of papers intends to review the status of this discipline and propose some novel applications of the recently developed interactive and distributed system in medical consultation and education. Our approach is built on the notion that interactive and distributive capabilities of the system open new dimensions in the area of medical education and patient’s consultative treatment. The presented applications use a multi-user, collaborative environment with multimodal human/machine communication in the dimensions of sight, sound, and touch.

Need for telemedicine

Telemedicine has various aspects including TeleConsultation, TeleDiagnosis, TeleEducation, TeleTraining, TeleMonitoring and TeleSupport and incorporates complete information about patients’ medical record (in the same hospital or any virtual hospital online). Patients can also carry their basic medical records stored on their digital identity cards, for keeping communication reliability between medical practitioners. In case of emergencies, the patient transport may become very difficult due to adverse weather conditions or for poorly available materials or loss/failure of normal infrastructure; and at times the patient may be too critical to be transported. Many times a small population may be either isolated or spread over a huge stretch of area and be devoid of professional medical care and facility. Often health clinics may be either dysfunctional or may not have any facility for treating serious illnesses or injured patients. Remote area clinics do not have the requisite trained manpower or medical facilities for intensive care of serious patients. At times even if expert advice is available, there may not be people capable of carrying out even resuscitation – as in intubating a patient with a cardiorespiratory arrest. Another example where telemedicine may be of real use is on high seas, where big ships commanded by small crews cannot afford the luxury of a doctor. Such geographically isolated areas can be connected by network connectivity with reputed medical colleges and hospitals and telemedicine can play its role. Not only can this particular use of technology be helpful in management of disaster situations but it may also be helpful in predicting disease outbreaks, as a recent article in this journal brought to fore the efficacy in predicting cholera outbreaks.

Telemedicine system is well suited for disaster management as it is even more reliable, than the physical system. Nitzkin et al. (1997) has discussed the reliability of telemedicine system and other related issues. Conventional examinations and telemedicinal examinations were conducted on a number of matched pairs of observations. The study shows that some experience is necessary for practicing telemedicine as the findings raise some doubts about the reliability of occasional consultations done by doctors inexperienced in the use of the technology. The study revealed that for ophthalmology, physical therapy and cardiac auscultation, 91.2 percent of the conventional findings and 86.5 percent of the telemedicine findings were identical. The kappa coefficient* on a matched pair analysis was 0.66. For tracing and images both conventional and telemedicine findings showed 92 percent reliability with a kappa coefficient of 0.87. The reliability factors prove that telemedicine can be applied to, Tele-radiology, Tele-surgery, Tele-dermatology, Tele-otolaryngology and Tele-pathology.

The various types of data that can be transmitted are voice, clinical findings, video clippings, high resolution photographs, radiological images like plain X-rays, CT scan and Ultra sound etc. Malone et al (1998) objectively uated the effect of different bandwidths on the ability to interpret obstetric ultrasound scans transmitted live over a commercial telephone network.

Usually telemedicine projects face difficulties[ii] in the form of low technology proficiency of health professionals in remote areas, language barrier, and lack of human resources, lack of proper infrastructure, low bandwidth or poor connectivity, and lack of familiarisation with telemedicine services.

Telemedicine support facilities

Telemedicine can enable / facilitate various other services also, such as: Continuing medical education for health professionals and special medication education seminars for individuals and groups in remote locations.

Nursing call centres for referrals and patient services.

Patient consultations: Audio, video, and data are shared between a patient and physician for the purpose of rendering a diagnosis and subsequent treatment plan.

Remote patient monitoring uses special devices to remotely collect and send data to a monitoring station for interpretation. This could include checking vital signs, such as blood glucose or ECG. This is usually accomplished with speciality hardware devices and with integrated/fixed communications capabilities.

Specialist referral services usually involve a specialist assisting a general practitioner in rendering a diagnosis. Video-conferencing enables the patient to see a specialist during a remote consultation accomplished in real-time, through transmission of images, such as x-rays, along with patient data for later viewing. This is especially important for patients living in rural areas, or for those who are too ill to travel great distances to visit a specialist or a clinic.

Disease management is a relatively new telemedicine application. It refers to the on-going consultations between a patient and two or more multi-disciplinary practitioners whose intent is the treatment and management of long-term disease. This often involves interaction between medical, pharmaceutical and behavioral professionals on a single case. With the increasing aged population and subsequent increase in certain diseases such as type II diabetes, HIV, etc, the disease management arena is expanding. It may also be helpful in reducing visits to a specialists clinic where an online consultation may suffice and if the doctor is satisfied, the visit may delayed further thus reducing transit costs.

Support services in campus facilities and remote offices. Healthcare is often rendered in a distributed office environment, and almost every process falls under privacy and other regulatory requirements. As such, nursing and support services are often the first to adopt secure telemedicine and communications-related technologies in order to reduce inter-office delays, improve the patient experience, and to reduce operational costs.

Issues and heavy costs associated with the present telemedicine models in India

In India the implementation of the concept of telemedicine involving hospitals has been halfhearted and has really not taken root. The causes are many; one of the main being the inability to take the ground realities about illiteracy and absence of compulsory social medical care into account (in a developing economy it is very common), though there has been a rapid development of communication technology. More importantly, how do we measure the impact of telemedicine on the health systems of developing countries? Will strengthening secondary care for a few disadvantage basic primary care or environmental health for the many? Will investment in the required rural telecommunications be at the expense of providing drinkable water? Will developing countries too be seduced by the expensive impact of technology led tertiary care for the few, while ignoring the endemic impact of modified health related behaviour? Will opportunistic global traders exploit the vulnerable? This brings us to the question once again -whether development will lead to better medical services or better medical services will help in accelerating development. The Classic- who came first? Egg or the hen conundrum!

The basic unit in a medical care set up is a Primary Health Centre (PHC) for every 5,000 population They are supposed to provide a wide range of services such as health education, promotion of nutrition, basic sanitation, the provision of mother and child family welfare services, immunisation, disease control and appropriate treatment for illness and injury. Each PHC is a hub for 5-6 sub-centers and covers 3-4 Villages and is coordinated by a ANM (Auxiliary Mid Wife) PHCs also work as Referral Centers for Community Health Centers (CHC), which is a minimum 30 bedded-hospital or higher at the Taluk or District Levels. Model projects were launched at various PHC`s and implemented on small scale. Their impact and usefulness to the large rural audiences is fairly limited and does not even constitute 0.0001 % beneficiaries in India.

Generally the motive behind launching these kinds of model projects is to serve the particular specific requirements of an NGO or demonstration of technology and they usually end up as means for garnering some limelight. Many of them were started with fanfare and unveiled plans to interlink thousands of PHCs in the country and now they are barely running the single outfit they had originally commissioned. As it is with any technology project, it is very easy to set up by installing a set of machines and links, but it needs real motivation to sustain them on a continuous basis. Except for one or two projects the rest of them aimed at connecting one city based hospital with a metropolitan hospital. The rural focus remained limited to couple of model projects.

Government which must be encouraging viable models to remove the lacunas in the primary care access and coverage problems, has not been able to do much and is following the regular route of construction of new PHCs and supplying sophisticated equipment. They are oblivious to the fact that all these infrastructure developments cannot motivate the doctors and Reproductive Health Specialists to the villages.

Where as dialup models are not effective, the costs and maintenance of VSAT based network is prohibitively expensive and requires skills to set up and maintain. This hinders the opportunities for business and governments to mass replicate the model projects. The end result being that rural India is not ready with very costly and heavy overheads involved present models of telemedicine.

The pace of technology development has fast outpaced the development of nodal centers resulting in a situation where technology that may have been approved may have become dated by the time of implementation.

Practicing telemedicine consultant: A perspective

In the past few years we have seen the efforts of various technological groups to incorporate telemedicine in their integrated plans for providing better health care .Notable among these have been the military, corporate hospitals and large apex institutions such as AIIMS. However, they have somehow not managed to meet their objectives as they got lost either in beauracratese or the technology involved got outdated with every new version of computers.

We are dealing with a set of people who may not be very technology savvy. For example, the remote areas from where the doctors or the paramedical staff may want help may not have computers, electricity or Internet connections. On the other hand the Doctors from whom this help maybe sought may so highly specialised in their fields that they may actually be incapable of using the interfaces on their own and may require help in dealing with technological gizmos, which in the minds of others may be of a very basic variety. Maybe, this also led to a concept of having dedicated connections and dedicated nodes, which had huge logistics requirement and were expensive and therefore could not really take off. Meanwhile, technology grew by leaps and bounds and with the easy availability of the Internet and mobile telephony telemedicine hubs may soon become an anachronism. The need therefore maybe to be able develop systems that can be connected through mobile telephony, or the ubiquitous internet and which can made cheaply available at the cost of an SMS or an MMS, use less bandwidth and maybe accessed by a busy clinician by just plugging it into an adequate port connected to a laptop, a TV screen or a personal computer. This will not only adequately take away the financial burden but also make it more accessible and user friendly. The more important requirement would be finding the appropriate doctors to be available at the required time and this system of human resources will have to be adequately developed and put in place. In future, even distant surgery with the help of robots may become possible as a routine practice. A recent example is a news item cited in the Times of India dated Dec 08, 2008 on page 15(Pune edition), where a doctor who was not trained in surgery manage to amputate the shoulder of a teenaged boy in Congo, while operating on the basis of SMSes that he received from a colleague in faraway London. This subsequently saved the boy’s life.

An example may be drawn in the management of two major diseases that contribute largely to the mortality and morbidity and where timely institution of therapy and involvement of physicians may save lives and reduce physical disabilities. These are Acute Myocardial infarction and Stroke management. The onus in management of acute myocardial infarction is shifting from drug induced fibrinolysis of the clot with the use of `clot busters’ to a more invasive strategy involving Primary angioplasty where the operators take the patient up immediately for breaking up the clot mechanically.

However, time and logistics are the problem, as cardiac catheterization laboratories are expensive and can only be started in high catchment areas. Therefore, the patient who is suffering from a heart attack may have to be transported for this treatment. This may take time and therefore it maybe more prudent if the patient is thrombolysed either enroute to the hospital by paramedics, a concept referred to as `Pre-hospital Thrombolysis’, in which the ambulance should have the ability to transmit ECGs of the patient to an attending doctor who can then take a decision on the management protocol to be followed. Similarly, in an ischemic stroke it is advisable that the patient is thrombolysed early. However, that decision is hard to take even by Internal medicine specialists and the interpretation of the CT Scan by a trained neurologist maybe imperative. This again is an expensive proposition but quite in the realm of telemedicine where timely action may result in preventing lifelong crippling disabilities in an individual.

Conclusion

Telemedicine is not the magic pill that will cure our ailing health care system, but it is a potentially miraculous method that promises improvements to our delivery systems, bettering quality, access and eventually even costs. Telemedicine will not thrive on a one-shot approach; it requires a regimen of treatments. Its future solution to our health care system’s problems of access, quality and costs is best insured by a collaboration of efforts�by the center, state and private sectors and by the bureaucrat, physician and technician. Regardless of telemedicine’s potential, significant regulatory and policy barriers threaten to disrupt the development of distance medicine. These barriers include reimbursement limitations and uncertain funding, cumbersome credentialing requirements, legal liability uncertainties and malpractice exposure, unclear data on cost-effectiveness, and a lack of uniform national practice standards and telemedicine standards. Additionally, telemedicine has neither practice guidelines nor measurement criteria, and scant information exists regarding clinical efficacy. There is even debate in the medical community regarding telemedicine’s direction and infrastructure. As a result, telemedicine is being legislated, regulated, studied, reported, journalised, conferenced, advanced, propounded, debated, bibliographed, and webbed.Telemedicine is being researched and piloted, both on small scale and large commercial endeavors. It is the subject of multi-government laws and laws in waiting. However great telemedicine’s promise, its full potential to address issues of quality, access and costs are imperiled by the lack of a strategic plan.

Telemedicine can open a world of health-care delivery by building clinical bridges between patients and available health care, albeit contingent upon the costs and development of ancillary infrastructure and services. The telemedicine experiences in this study transcend India. Such experiences could have far-reaching benefits for poorer communities in developed countries as well as for developing countries. This collaborative effort should have one driving force and end: acting in the best interest of the patient. By moving toward this goal, all players can compete and even without a strategic plan, guarantee improvements and better access and treatments to patients. These are real issues, but they should be debated on the grounds of local values of appropriateness and priorities. The pull of needs, not the push of supply, should be the determinant. The voices of local experts, rather than external commentators, should be heard as the lead voices. Initiatives to identify culturally and locally relevant yet sound sites should be encouraged and open debate initiated on the core issues. If telemedicine is to have any significant and safe impact in developing or other countries, global agencies such as the World Health Organisation need to encourage and accumulate studies on its local impact, while also seeking a global framework to ensure its safety and ethics.Opportunities for benefit from telemedicine are great; so are the opportunities for harm. The future debate should rest on issues of local health priorities and impact, and on global ethics to ensure sustainable assured solutions.

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

  1. Akay, M.; Marsic, I.; Medl, A., and Bu, G. (Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, USA
  2. Malone, F. D., A Athanassion, J Nores, M E. D’Alton, Effect of ISDN Bandwidth on Image Quality for Telemedicine Transmission of Obstetric Ultra-sonography, Telemed. Journal, Vol. 4, 1998, pp. 161 � 165.
    Bansal, Mohan, Medical Informatics � A Primer, Tata McGraw-Hill Publishing Company Limited, New Delhi, 2003 Takeda H., Y Matsumura, T Okada, et al, Functional uation of Telemedicine with Super High Definition Image and B-ISDN, Medinfo 9 Pt 1; 1998, pp 311-314
    Choi J, Y Kim, J Lee, et al, Features for a B-ISDN Telemedicine System and its Application, Medinfo 9 Pt 1; 1998, pp. 307-310
    Johnston B, L Weeler, J Deuser, et al, Outcome of the Kaiser, Permanente Telehome Health Research Project, Arch. Fam. Med., Vol-9 (1), pp 40-45, 2000
    Rao M S and I C Rao, Telemedicine and the Internet – Practical approach, Proceedings of National Conference on Medical Informatics, Hyderabad, pp 46-53, 2000
  3. Article : Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals and primary health care centers ; Ranganayakulu Bodavala, President THRIVE .
  4. In 1995, this was a key comment of Douglas A. Perednia & Ace Allen. Allen, a wealth of telemedicine knowledge, still agrees that more data on cost-effectiveness is needed and that this is an area that should be further researched (Telephone conversation between author and Dr. Allen on March 10, 1998). . See Even with Barriers, Telemedicine Still Potential Revenue Generation for Telco, Broadband Network News, Vol. 6, No. 6, March 19, 1996.
  5. .Department of HHS was mandated to conduct demonstration project in rural underserved areas, P.L. 105;
  6. Telemedicine Report to The Congress, Department of Commerce (January 13, 1997) (51). . Telemedicine Today, published its first issue in the Fall of 1992 and is an up-to-date account of current research, events, projects and funding. .
  7. See Telemedicine: Past, Present and Future, written in 1995, contains 1,634 citations to articles, books and dialogues relating to telemedicine. Today, a similar task would be daunting because of the exploding wealth of material. In the past few years web sites and numerous journals devoted to providing information on telemedicine have been created. .
  8. See FDA, Center For Devices and Radiological Health on the World Wide Web at <https://www.FDA.gov/cdrh/telemed.html>.
  9. The two physicians who many be considered the real “grandfathers” of telemedicine, Douglas A. Perednia and Ace Allen pointed out the incredible number of federal agencies and state agencies involved in both the funding; research and telemedicine demonstration programs.
  10. See Douglas A. Perednia and Ace Allen, The Journal of the American Medical Association, Feb. 8, 1995, WL Database AMA-JNLS.
  11. Lam, CLK. Knowledge can flow from developing to developed countries. BMJ. 2000;321:830 Rigby, M. And into the 21st century: telecommunications and the global clinic. In:
  12. Rigby M, Roberts R, Thick M. , editors. Taking health telematics into the 21st century. Abingdon: Radcliffe Medical Press; 2000. pp. 187�206
  13. Rigby, M; Forsstr�m, J; Roberts, R; Wyatt, J. Verifying quality and safety in health informatics services. BMJ. 2001;323:552�556

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