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TELEMEDDICINE

Telemedicine literally means "distance healing" being derived as it does from the Greek word "tele" meaning "distance" and the Latin term "mederi" meaning, "to heal". It employs information technology, through the judicious use of computers, related software, and telecommunication systems comprising of compatible telephone lines, fiber optic cables and satellite linkups, etc., to provide premium quality health care. Worldwide, people living in rural and remote areas struggle to access timely, quality specialty medical care, primarily because specialist physicians are more likely to be located in areas of concentrated population (i.e in the urban areas). Due to the innovations in computing and telecommunication technology, many elements of medical practice can be accomplished when the patient and health care provider are geographically separated. This separation could be as small as across town, across a state, or even across the world. Broadly defined, telemedicine is the transfer of electronic medical data (i.e high resolution images, sounds live video, and patient records) from one location to another. This transfer of medical data may utilize a variety of telecommunications technology, including but not limited to: ordinary telephone lines, ISDN, fractional to full T-1's, ATM, the Internet, intranets and satellites. Telemedicine is utilized by health providers in a growing number of medical specialties, including but not limited to dermatology, oncology, and radiology, surgery, cardiology, psychiatry and home health care. History of telemedicine Telemedicine has been in use in some form or the other for over 30 years. The National Aeronautics and Space Administration (NASA) played an important part in early development of telemedicine (Bashshur and Lovett, 1977). NASA's efforts in telemedicine began in the early 1960's when humans began flying in space. Physiological parameters were telemetered from both the spacecraft and the space suits during missions. 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. NASA provided much of the technology funding for early telemedicine demonstrations. A book by Rashid L. Bashshur published in 1975 lists fifteen

telemedicine projects active at that time. There were several pioneering efforts not only in the US, but all over the world. A few of them are worth examining briefly.

Video Requirements for Remote Medical Diagnosis SCI Systems of Houston to conduct a study to determine the minimal television system requirements for telediagnosis. The experiment was conducted with the help of a simulated telemedicine system. First, high-quality videotape was made of actual examinations conducted by a nurse under the direction of a physician watching on closed-circuit television. This was the baseline for the study. Next, these videotapes were electronically degraded to simulate television systems of less than broadcast quality. Finally, the baseline and degraded video recordings were shown (via a statistically randomized procedure) to a large number of physicians who attempted to reach a correct medical diagnosis and visually recognize key physical signs for each patient. Six television systems were investigated: two systems were compatible with transmission over full bandwidth television channel, while with the other four allowed more detailed investigation of the frame rate and horizontal bandwidth required for each medical case. The following four results were found: 1) statistical significance between means of the standard monochrome system and the lesser quality systems did not occur until the resolution was reduced below 200 lines or until the frame rate was reduced below 10 frames/second; 2) there was no significant difference in the overall diagnostic results as the pictorial information was altered; 3) there was no significant difference in remote treatment designations as a function of TV system type that would cause detriment to patients; 4) the supplementary study of radiographic film televised transmission (25 cases) showed that no diagnostic differences occurred between the TV evaluations and the direct film evaluations for TV resolutions above 200 lines if special optical lenses and scanning techniques were utilized.

TeleMed The advanced Computing Laboratory developed TeleMed, an electronic medical record for managing tuberculosis patients through collaboration with Center for Immunology and Respiratory Medicine. Telemed provides a snapshot of patient data,

presented chronologically with access to laboratory test results, clinical history, radiology images, reports and treatment history. A particularly valuable feature allows physicians to annotate the medical record, either orally or in writing, for collaborating physicians to retrieve. Medical expertise can also be exchanged in real time, with both users sharing the same screen and with each having the capability to drive the mouse-pointer. Telemed now available in the Internet using Java based technology enables physician specialist to Support primary care providers in the management of complex medical problems. The technology creates a "virtual patient record" that allows the integration of databases from multiple clinics and multiple providers across geographically separated areas. This permits individual health care facilities to continue to own and manage their own data while making the data accessible to others treating the same patient. TeleMed provides a time-oriented record of the patients medical history but only retrieves the actual data on demand, thereby minimizing the bandwidth requirements of the network capabilities. Distributed ownership of the data means that only one copy of the data exists, and the copy remains where it was located. Types of technology Telemedicine is an application, not a technology, although the term is often misapplied. Two different kinds of technology make up most of the telemedicine applications in use today: (i) store and forward technology (ii) two way interactive television (IATV) Store and forward technology is used in Telemedicine for transferring digital images from one location to another. A digital image is taken using a digital camera, ('stored') and is then sent ('forwarded') to another location. The image may be transferred within a building, between two buildings in the same city, or from one location to another anywhere in the world. The DICOM Standard was developed according to NEMA Procedures. It is developed in liaison with other Standardization Organizations including CEN TC251 in Europe and JIRA in Japan, with review also by other organizations including IEEE, HL 7 and ANSI in the USA. Teleradiology, Telepathlogy and Teledermatology are the most common application in use today.

Interactive television (IATV) is used when a consultation between the patient, primary care provider and specialist is necessary. Videoconferencing equipment at both locations, typically an urban and rural location, allow a 'real time' consultation to take place. This means that the patient does not have to travel to an urban area to see a specialist, and in many cases, provides access to specialty care when none has been available previously. Almost all specialties have been found to be conducive to this kind of consultation including psychiatry, internal medicine, rehabilitation, cardiology, pediatrics and gynecology and many more. If telemedicine is being used today, where is it? 1. By video, e-mail, telephone etc, consulting with doctors across, state, national, and international borders is now being done everyday. This teleassistance is rapidly growing. 2. Video conferencing for diagnosing or educational purposes. A doctor in one hospital can talk with a patient or doctor in another area to speed diagnoses and their accuracy. A surgeon can watch a procedure remotely and consult to make sure things go smoothly. Medical school students can learn medical procedures without having to be in the operating room. 3. Sites containing medical information are popping up on the web every day. One can go to find information on a certain condition or treatments, read up on medical interests, buy products, or even visit a "cyberspace telemedical office". 4. The use of telemedicine to reach undeserved areas such as rural sections of the country or military bases in other countries is a huge area being researched now. The benefits of these services could be amazingly far reaching. 5. Remote supervision of physicians' assistants or nurses can be done by means of telecommunications. 6. A highly controversial, but possible, use of telemedicine for the future is the establishment of large medical records databases. 7. An already extremely common use of telemedicine today, research databases such as Medline make medical research infinitely more efficient than before. Benefits of telemedicine

The benefits of telemedicine are many. Instant access to information, whether it is about a certain patient or a certain topic, can be essential or even life saving. The Telemedicine Research Exchange notes the story of a rural doctor who had never done an amputation before being helped through the procedure by a well-practiced physician over a video link. The two saved the life of the amputee, who did not have enough time to reach the larger facility. A multifold increase in efficiency for all types of medicine is another large benefit. Travel times for patients and doctors could be significantly reduced as well as research time and "paper handling" of medical records. Accuracy of diagnosis is always a major concern for the medical community. With telemedicine it will be easier for a doctor to get a "second opinion" on their diagnosis of a patient. With greater access to help, more patients will be treated correctly, the first time. This leads to more benefits like quicker average recovery time, less usage of needless medicines, and reduced costs to patients and hospitals. Self-help will increase with the online availability of so much medical information. Informed patients can result in eliminating needless visits to the doctor, patients will be better equipped to express symptoms to the doctor when they go. Telemedicine promises the day of individualized care guidelines for the ill and easier long-term monitoring of chronically ill patients. Better reaching geographically difficult areas, such as the rural communities is one of the most important promised benefits of the telemedicine age. Improvements in everyday medical research have already been seen. Searching a topic for clinical or educational purposes is amazingly simple and requires only a fraction of the time the same research used to take. Telemedicine in India Telemedicine in India has not taken off, as it should have; this is mainly due to poor telecommunication facilities, high costs, non-availability of medical records in digital form. Apollo Hospitals group based in Chennai has plans to set up 3,200 telemedicine centers in India. According to the Apollo Chairman, Dr. Prathap C. Reddy, the speed with which the centers will be established will be determined by the speed of the

infrastructure development in the country. They hope to eventually connect 2,600 primary care centers, 500 secondary care centers and at least 100 tertiary care centers all over the country. They have recently linked the Aragonda village (pop. 15,000) in Andhra Pradesh with Apollo Hospitals at Hyderabad and Chennai. A primary care facility was established in the village, which will be connected to the Apollo Hospital. Since 80% of the population in India is rural and 80% of the medical community live in urban areas, it means that access to healthcare is limited for many rural inhabitants. Apollo hopes to provide a successful working model of telemedicine which will also allow for implementation of population control programs, create a channel for AIDS awareness, bring the private insurance sector initiative to the rural population, and be used for epidemiology monitoring. (Source: Business Line, June 22, 2000) An Event Recorder (ER) is a small electronic equipment resembling a TV remote control, it has no cords attached to it. The patient simply has to place it on his chest, push a button and wait for a minute for recording the ECG. This done he has to dial the telephone number of his doctor and place the equipment on the mouthpiece as per directions given, and press the same button again. The ER converts the electronic signals into audio signals, which again get converted into electronic signals on the doctor's personal computer. The ER has been tested on domestic flights, in moving vehicles, offices and parks. It has worked to the satisfaction of the medical experts. The Escorts Heart Foundation in Delhi to provide assistance to patients is using the ER, the services are available in Gujarat also. Escorts Heart Alert Service EHAS is a development in cardiac telemedicine that has revolutionized the cardiac care in India. It saves time and life by providing an expert ECG interpretation over telephone within minutes of any chest complaint. EHAS is first of its kind in India, which opens a new dimension in providing instant cardiac attention. It's a development in cardiac telemedicine that has already been proven across Europe and USA where it has FDA approval. It operates 24 hours a day, 365 days a year. A newly commissioned Heart Command Centre (HCC) backs EHAS and a fleet of mobile cardiac cares ambulances.

This will provide the highest possible level of critical lifesaving service unparalleled in our country before. New Search Engine The Telemedicine Information Exchange (TIE) programmer, Burt Jurgens has developed the Telemedicine Search Engine (TSE) which will greatly increase the telemedicine information searching power for TIE users. Enter a search item in the TSE field (found on the home page http://tie.telemed.org), and your term will be searched in over 60 telemedicine related sites, which are currently linked to from various places on the TIE. Using this search engine one does not have to qualify any of the terms with the word "telemedicine", as the searching will be done only on the telemedicine web pages. GUIDELINES FOR THE IMPLEMENTATION OF A TELEMEDICINE PROGRAMME Sensitizing In sensitizing government decision-makers, health and telecommunication professionals, concerned communities and users, the following points should be highlighted: 1. Telemedicine is not meant to replace the physician; 2. The value of telemedicine lies in spreading medical knowledge, through the use of telecommunications, to remote areas where it is not available; 3. No sophisticated communication infrastructure is required in order to develop telemedicine applications. Evaluation of the present situation 1. Both sanitary and communication infrastructure should be evaluated. 2. The evaluation of sanitary infrastructure should cover the existing problems, needs and priorities, as well as the geographical distribution of the primary, secondary and tertiary assistance centres. Consideration should be given to communication infrastructure; the links currently available and future expansion plans. Creation of interdisciplinary groups

1. Working groups should include members from the health and telecommunication sectors, as well as other sectors that may be able to share the structure to be developed (e.g. education, tourism, production). Integration of telemedicine The telemedicine programme should not be isolated, but must be made part of the global health project. Training of health professionals Health professionals should be aware of: 1. available tools; 2. applications that can be developed; 3. how to develop such applications; 4. how to use the applications developed. Implementation of pilot projects Aspects to be considered for the implementation of pilot projects: 1. Identification of a project-leading group; 2. Identification of existing problems; 3. Definition of quantifiable and verifiable objectives; 4. Selection of technology (physical links, types of equipment and systems to be used, as well as possible combinations thereof); 5. Definition of the cost of the infrastructure: cost of initial installation, cost of operating the system and cost of its maintenance; evaluation of the cost/benefit ratio of the different systems. 6. Comparison with reference models of existing projects (benchmarking); when developing a project on distance medical education (tele-education), there is also a need for a roject-leading group to be responsible for providing valid content on a permanent basis; organization of the pilot project into phases, with an individual programme for each phase; monitoring and evaluation of the projects. It is important to verify the number and type of applications developed, the number of users, the level of diagnostic quality, the amount saved by the use of telemedicine (in terms of transportation, unnecessary procedures, etc.); feedback between

designers, operators and users of the project in order to allow the necessary adjustments/corrections; assurance that the project is sustainable; identification of funding sources to get the project started and keep it going. 7. Telemedicine and the national health plan. Based on the results of the pilot projects, it should be possible to generate specific application models to be included in the national health plan. 8. Education for telemedicine. It is of crucial importance to introduce telemedicine into formal health education programmes. Need for resource optimization 1. There are multiple applications running on low-cost and high-availability links such as radio, telephony, Internet, etc. Given the shortage of resources and the need to share those that are available with other priority projects, it is essential to carefully explore the possibility of using low-cost links before adopting high-cost solutions. 2. It is important that the systems adopted use configurations that are suitable for future upgrading. 3. The mix of technologies and formats serves to optimize the quality and use of the applications. Resources should be used in a flexible way in order to achieve the maximum benefit at the lowest cost. Examples: Cross-consultation: The Internet could be used for administrative aspects such as identification of specialists, making appointments, sending medical records, etc., with a facility like ISDN being used only for discussion of the case itself. 4. Education: Even though tele-education systems are available, videoconferences, courses, etc. could be recorded, allowing them to be multicopied, made available through the Internet, etc., and distributed to a much wider audience. 5. To optimize the use of resources, the organization of regional or subregional projects should be promoted. 6. The need for setting up demonstration centers in leading hospitals laboratories with terminal equipment that is compatible with technology in the developing countries.

7. The need to enhance participation by health sector delegates, since they are familiar with needs. Medical Transcription With medical expenses being very high in the USA, most patients cannot afford to pay from their own pocket. Therefore, the majorities rely on medical insurance to take care of such expenses. In order to claim the money for services rendered, doctors and hospitals first need to submit detailed reports to the insurance companies. Preparing such extensive reports on every individual patient would prove to be too time consuming for the medical professionals and facilities. Therefore, physicians and other healthcare professionals simply record the basic information about every case on digital media or tapes. The dictations are then sent to professionals who are trained to go through, interpret and structure the dictations into full fledged reports comprising patient assessment, therapy diagnosis, procedures, etc. This process of converting dictations into reports is called Medical Transcription, and the professional who specialize in this IT-enabled service are called Medical Transcriptionists. The job requires excellent listening skills, accurate typing ability, good written English, and extensive knowledge of medical terminology. Initially, most Medical Transcription jobs used to be outsourced from Mexico, Israel and Ireland. While Mexico did not possess sufficient English speaking professionals, the others charged a lot for their services. Thus, the focus shifted to the Indian subcontinent and Philippines. Today, India with its large pool of English speaking population, ideal virtual time difference with USA, and modern telecommunications network, is busy emerging as the new MT hub of the world. Promising ample career opportunities to those keen to take up this IT-enabled profession. -------------------------------------------------------------------------------------------------

Integrating EMR With Telemedicine to Provide Better Community Health-Care In the times of struggling economy, the health service providers are hard pressed to provide high quality patient care in a cost effective manner. The increase in competition in health care sector and slow down in economy has resulted in decrease in profit margins for hospitals and multi-

location clinics. To sustain the business, during recession it is necessary to reduce daily operational costs without compromising the prevalent quality standards. The highly competitive atmosphere has made health organizations to make a foray into untapped health care sectors like Telemedicine to increase their business revenues.

The Challenges to Long Distance Health Care Delivery In remote areas where health care facility is non existent or scattered over large distance, it becomes quite difficult for the community members to get proper and timely health service. This poses a big challenge to the health administrators, as they look at options to integrate the remote communities into mainstream healthcare system. Time and distance are the biggest hurdles, which patients face when it comes to accessing proper medical aid.

In urban and well developed cities, trauma patients can receive timely medical attention in hospitals and specialized clinics. In case of remote location, people suffer because they have no access to critical health care infrastructure. To avail such facility they have travel long distances to cities or major towns. This induces physical stress in the patients and deteriorates their medical condition, further. Moreover transporting the patient over long distance increases the overall cost of treatment.

Technology as an Aid The rapid growth of modern communication and medical technology has made it possible to develop customized solutions for typical healthcare problems, usually faced by the patients in the past. Providing high quality health care services to far flung communities is a reality now. The developments in fields of medical documentation system like EMR and availability of latest wireless technology like Worldwide Interoperability for Microwave Access (WIMAX) make it possible for physicians to treat remote patients. The concept of telemedicine is to take the health care service to the patients doorsteps instead of people traveling over long distances to health centers.

- It provides clinical decision support. - Captures complete patient health data and customizes it. - Provides complete patient charting. - Manages patient scan/images. - Allows patient to access their medical information online.

- The information can shared with medics at distant places.

The data entry, which was biggest inhibition for the physicians, is no more a problem for them as EMR system enables input of data is quick and easy manner through following means: - Keyboards/touch screens are used for input of primary patient data. - Mouse/touch screens for diagnosis, patient history and findings. - Slit and Fundus camera for video signal transfer. - Digital camera, DICOM and Non-DICOM instrument for transfer over cable connection. - Through Voice storage and transmission, and transcription process. This all input techniques make it easy to convert the data into electronic form. Once the data is digitized it can be safely stored, transmitted and processed between two different entities. The next step is to create a platform that enables smooth exchange of the health data between the patients and doctors.

Telemedicine and Wireless Transmission Technology Telemedicine is branch of the modern medicine that employs modern communication technology like Worldwide Interoperability for Microwave Access (WIMAX), to transmit health data over long distances. The specialist or physician can send or receive medical health record from the remote patients. The x-ray reports, radiology and MRI scans, ECG signals, video and audio records, and other crucial health reports can be easily converted into digital format by EMR technology and routed to the actual point of use, through a wireless medium. The audio and video signals are converted back into original form to display the true images and data. Through WIMAX, it is possible to send and receive the video and audio signals, simultaneously. This is an important feature that greatly helps in Tele-monitoring. For critical patients, especially those suffering from paralysis and cannot be moved over a long distance, Tele-monitoring is a boon. It allows the doctors to keep a close eye on the vital signs through continuous access of MRI scans and ECG signals.\ Telemedicine also helps in live video conferencing, with a specialist on one end and patient with or without a local physician on the other end. People and both the ends, hundred of miles apart, can see and talk with each other. The consulting specialist is made aware of the existing health problem by the patient. The specialist then prescribes a treatment which the patient can easily follow in the comforts of home. WIMAX provides cost effective healthcare solution by delivering a feasible option, which creates a seamless connectivity between physicians, paramedics, local doctors, nurses and patients, spread over a great distance from each other. WIMAX technology provides high degree

of interoperability between different local area networks. It is cheaper for health service providers to employ WIMAX technology and integrate EMR and Telemedicine with satellite transmission and wireless local area networks (WLAN), compared to huge investment needed towards creating a physical network of telephone exchanges over inhospitable terrain to transmit patient health information, electronically. Conclusion By integrating EMR with Telemedicine through use of WIMAX technology, it has become quite easy to diagnose and treat patients in remote areas. The patients can stay at home and at same time continue to receive the same quality of health care, which they would have received at the hospital. Further compliance to HIPAA norms ensures that patient health information is securely exchanged and stored. The relatives of the patient are also saved from the disruptions to their daily routine and are more comfortable in providing family care to the patient in the settings of the home, under careful watch of the specialist from a distant hospital. This all translates into better care with no expenses towards patient transfer and accommodation at hospital. Telemedicine is boon for remote communities.