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Telemedicine in India

Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in critical care and emergency situations. Although there were distant precursors to telemedicine, it is essentially a product of 20th century telecommunication and information technologies. These technologies permit communications between patient and medical staff with both convenience and fidelity, as well as the transmission of medical, imaging and heath informatics data from one site to another. Early forms of telemedicine achieved with telephone and radio have been supplemented with video telephony, advanced diagnostic methods supported by distributed client/server applications, and additionally with telemedical devices to support in-home care.

The Range of Transmission Media Telemedicine has used various terrestrial and space-based (satellite) transmission media. The medium that is used is important in part because its bandwidth or bit rate (the amount of information sent per unit of time) limits the type of technology that may be used. Narrowbandwidth systems, such as ordinary telephone lines, are inexpensive but lack the capacity for full-motion video. They may be adequate, however, for transmitting still images, voice, text, or data. No single technology or bandwidth is best for all telemedicine purposes; rather, each system's capacities and capabilities must be determined by the needs of the users. Broad-bandwidth networks have transmission rates that permit interactive, full-motion video. For example, T1 lines have a relatively high bit rate of 1.544 megabits per second. They are not, however, available in many rural and frontier areas. Interactive video may be used with narrower bandwidths if data compression algorithms are also used, but the images are sometimes too jerky to permit resolution of detail or subtle movement. Broad-bandwidth networks are costly because transmission charges are directly related to bandwidth. This problem was partly addressed by rules that were developed by the U.S. Federal Communications Commission for the implementation of changes in the universal service program under the Telecommunications Act of 1996. These rules provide subsidies for telecommunications services, for which certain rural health care providers are eligible.

Clinical Uses of Telemedicine Most of the early telemedicine programs used interactive video to bring patients, referring providers, and consultants together. From 1959 until the 1970s, telemedicine was tested in medical schools, state psychiatric hospitals, municipal airports, jails, nursing homes, Native

American reservations, and other setting. Most of these early programs proved too costly to be self-sustaining and were terminated when external funding ran out. The clinical applications of telemedicine are even more varied than the technologies, although considerable attention has been focused on the use of interactive video for specialty and subspecialty consultation in rural areas. The generic interactive video telemedicine system typically uses fixed, studio-type video equipment to link a rural facility with an urban tertiary care center. Consultants communicate with patients and, often, with their primary care providers in an interactive situation. The precise configuration of these networks varies, ranging from a single source of referrals (for example, a rural community hospital) and a single source of consultants (such as an academic medical center) to complex hub-and-spoke networks involving many referring and consulting facilities. Almost every clinical specialty has used telemedicine in some way, although some have used it more than others. Radiologists, for example, have embraced the technology on a large scale. Cardiologists, dermatologists, and psychiatrists have been the clinical specialists most actively involved in telemedicine. The reasons for this are unclear, but this distribution may represent a kind of founder's effect because physicians practicing these specialties were among the clinicians to first become involved with telemedicine. Nevertheless, the fact that these specialists choose to see patients through telemedicine suggests that the medium is suited to many of their consultative tasks. A 1996 survey of almost 2400 nonfederal rural hospitals found that about 17% were participating in a telemedicine network of some kind (including services as limited as facsimile) and that another 13% had definite plans to begin using telemedicine. The number of clinics and outpatient facilities participating in such networks is unknown. Despite widespread interest in telemedicine, the actual number of patients per telemedicine program who receive telemedicine services remains relatively low. One recent survey of 80 programs (1032 sites on hub-and-spoke networks) estimated that about 21 000 consultations occurred in 1996 (mean, 37.4 consultations per site per year). Telemedicine has proven its feasibility in several challenging environments, including peacekeeping missions and the space shuttle (Pool SL, Stonesifer JC, Belasco N. Application of telemedicine systems in future manned space flight [Presented paper]. Second Telemedicine Workshop, 1975, Tucson, Arizona; [20-22]), and in the more prosaic settings of the home, clinic, hospital, and long-term care facility. It has been used for many years in Canada's Maritime Provinces; House AM, Keough EM. Distance health systems-collaboration brings success: the past, present, and future of telemedicine in Newfoundland [Presented paper]. Conference on Information Technology in Community Health, 1992, Victoria, Canada) and in Norway above the Arctic Circle. The program at Memorial University of Newfoundland in Canada has used many technologies, from facsimile (transmission of electroencephalograms) to interactive video. In addition to gaining improved access to care for patients, referring physicians may benefit from increased contact with their colleagues and greater opportunities for continuing medical education. One observer described telemedicine as a means by which medical schools can provide an extended warranty on medical education.

Other Impediments to the Growth of Telemedicine

Lack of reimbursement for telemedicine services is only one of several factors impeding the expansion of telemedicine. Licensure, for example, is regulated by individual states, and bills have been introduced or passed in some states that severely limit the interstate practice of medicine through telemedicine. Examinations assessing the competence of physicians are conducted using national standards, and patient outcome studies are conducted and practice standard guidelines are developed on a national, not a statewide, basis. State regulation of licensure-considered anachronistic by many-will continues to delay the spread of telemedicine technology. The European Union has faced a similar problem since the signing of the Maastricht agreement; that experience was addressed briefly at the Atlantic Rim Telemedicine Summit in 1997. A second difficulty concerns liability and malpractice. Some providers are concerned that the use of telemedicine may increase their risk (for example, a technical failure could lead to an adverse patient outcome, or telemedicine could provide an image of inferior quality that hinders a physician's ability to make an accurate diagnosis). Conversely, some physicians are concerned that if telemedicine permits high-quality care, they might be liable for failure to use it. The situation is compounded by interstate variability in the handling of malpractice claims. Because no one has yet been sued for malpractice related to telemedicine, it is not possible to assess the validity of these concerns. Finally, the issue of confidentiality remains contentious. The present system of medical records is already insecure, but there are additional concerns about the ability of electronic medical record systems to maintain an adequate level of security. In general, electronic records are probably more secure than paper-based charts, although a possible breach of security may mean that more unauthorized persons can obtain access to confidential data. The confidentiality problems that may arise can be classified as breaches of security and as inappropriate disclosure of individual patient information to persons who are unauthorized to receive it. Disclosure of information about a specific patient may be as likely with electronic records as with conventional paper records. Certain types of disclosure-such as the sale of lists of patients with a specific diagnosis to marketers, mailing-list brokers, or insurance companiesmay even be facilitated by the use of electronic databases. Access to electronic records must be carefully restricted to those who must have access to provide care. Even encryption and firewalls may be only temporary barriers to a person motivated to obtain unauthorized access. The problem is being addressed at several levels, both governmental and nongovernmental. Contractual and legislative protections are needed to provide the highest degree of security that is realistically attainable. The availability of electronic medical records is of great importance to telemedicine; as medical information systems evolve, telemedicine may disappear as a distinct entity and be subsumed into medical information networks. Thus, technological safeguards are also mandatory.

Conclusions Telemedicine is a general term that refers to a wide range of technologies and applications. The concept is almost as broad as that of medical care itself. It is futile to discuss such issues as the effectiveness or cost-effectiveness of medical care, and the same is true for telemedicine. Current efforts to develop a coverage and payment policy for telemedicine focus almost entirely on the use of interactive video consultation. Although this is an important application, it is likely to represent a diminishing percentage of the use of telemedicine in the next few years. If a rational coverage policy is to be developed, policymakers, payers, and legislators must recognize that one size does not fit all. Fine-grained distinctions must be made among different telemedicine applications. Scope of Telemedicine Earlier, the concept of telemedicine was alien to us and we could never imagine that such kind of thing would come into being. But, now with technological advancements this concept has gained momentum. The usage of various telecommunications by medical institutions and physicians for providing healthcare to their patients makes me wonder how technology can change our lives for better. Telemedicine aids caregivers in collection and transfer of still images, medical data, and live video and audio transmission. Some common methods utilized include the internet, satellite and ordinary telephone lines. Telemedicine benefits not only are availed in a single field but also across fields like radiology, psychiatry, cardiology and oncology. Telemedicine also helps in Diagnoses and treatments that include patient and physician education, telesurgery and medical administration video conferencing among healthcare providers. Surgeries like laparoscopy are performed in huge numbers in India whereas in countries like Africa they are rare and uncommon. Inadvertently, this knowledge sharing helps in driving the business along with fostering healthy physician relationship across countries. Telemedicine usage is positive for patients as well as economy. Telemedicine helps countless number of patients avoid nursing hospitals and homes allowing them to stay productive with less healthcare costs.

Limitations of Telemedicine While much of the literature highlights the benefits of telemedicine, it must be understood that there are limitations to this concept as well. Three of the main limitations for telemedicine is the privacy of medical Information, relationship or lack of a relationship between patient and provider, and the associated liability for the providers and organizations they are affiliated with. Below are more specific examples of limitations to the consumer provider and organization.

Consumers lowers level of trust between patient and provider Users may be intimidated by the technology (such as the elderly population) The uncertainty of their medical consultation privacy Providers requires a new design on the risk management practitioner-patient relationship with various patient populations in face-to-face consultation is now potentially further complicated by communication technology due to the change in dynamics in delivery clinicians with superior expertise in ethics and practice may lack technical expertise or perspective may have difficulty in communicating with seniors who have an increase in dementia and sensory impairment. Health Care Organizations requires to develop a telemedicine specific policies and procedures increased risk of liability limited technological support in rural areas the pace of development and capability of technology will force telehealth solutions upon us. As telemedicine continues to evolve, these challenges will be addressed to improve on the overall experience for all.

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