Tele medicine

INTRODUCTION
 Worldwide people living in a rural and remote area and struggle to access timely quality
specialty medical care to specialty health care, primarily it refers to use of tele
communication for diagnosis and treatment.

 The term 'telemedicine' derives from the Greek 'tele' meaning 'at a distance' and the
present word 'medicine' which itself derives from the Latin 'mederi' meaning 'healing'.

DEFINITIONS OF TELEMEDICINE:
 The World Health Organization defines Telemedicine as, “The delivery of healthcare
services, where distance is a critical factor, by all healthcare professionals using
information and communication technologies for the exchange of valid information
for diagnosis, treatment and prevention of disease and injuries, research and
evaluation, and for the continuing education of healthcare providers, all in the interests
of advancing the health of individuals and their communities”.

 The European Commission’s health care telematics programme defines

telemedicine as: "rapid access to shared and remote medical expertise by means of
telecommunications and information technologies, no matter where the patient or
relevant information is located."

 Telemedicine: The use of medical information exchanged from one site to another via
electronic communications for the health and education of the patient or healthcare
provider and for the purpose of improving patient care. Telemedicine includes
consultative, diagnostic, and treatment services.
 “Telemedicine is the transfer of electronic data (i.e. high resolution images sounds, live
video, and patient record / from one location to another).
 Telemedicine can be broadly defined as “Health care services delivered through tele
communication.”
 In this new era of the interconnected world it is being viewed as the future means of
delivering health care.
 Telemedicine as a” cost effective and practical method to deliver health care to all.”

HISTORY OF TELEMEDICINE
1906: ECG Transmission Einthoven, the father of electrocardiography, first investigated on
ECG transmission over telephone lines 1920. During this time, radios were used to
link physicians standing watch at shore stations to assist ships at sea that had
medical emergencies.

1924: The first exposition of Telecare Perhaps it was the cover showed below of "Radio
News" magazine from April 1924.

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1955: Telepsychiatry the Nebraska Psychiatric Institute was one of the first facilities in the
country to have closed-circuit television in 1955.

1989: NASA conducted the first international telemedicine program.

Trends observed nationally include:

 Using telemedicine in correctional facilities and home health care settings, can
significantly reduce the time and costs of patient transportation;
 Fine-tuning the management and allocation of rural health care emergency services by
transmitting images to key medical centers for long distance evaluation/triage by
appropriate medical specialists;
 Permitting physicians doing clinical research to be linked together despite geographical
separation, sharing patient records and diagnostic images;
 Improving medical education for rural health care professionals, where rotations are
made possible by linking several community hospitals together with the sponsoring
medical school.

SPECIALTIES
Telemedicine covers a growing number of medical specialties such as:
 Cardiology – Telecardiology ECG or electrocardiograph can be transmitted using
telephone and wireless.
 Radiology – Teleradiology is the ability to send radiographic images (x-rays, CT, MR,
PET/CT, SPECT/CT, MG, US...) from one location to another.
 Psychiatry - Telepsychiatry, another aspect of telemedicine, also utilizes video
conferencing for patients residing in underserved areas to access psychiatric services.
 Telepharmacy is another growing trend for providing pharmaceutical care to the patients
at remote locations where they may not have physical contact with pharmacists.
 Home Care, Emergency Care, Surgery, Dermatology, Oncology, Pathology,
Ophthalmology, Hematology, ENT, Nephrology, Diabetic care, Pre hospital Care, etc.

TYPES OF TELEMEDICINE
Telemedicine is practiced on the basis of two concepts: real time (synchronous) and
store-and-forward and Home Health (asynchronous).
Telemedicine process can be categorised in two ways i.e. technology involved and
application adopted.

(a) Technology involved:

 Real Time or Synchronous: Real time telemedicine could be as simple as a telephone
call or as complex as telemedical video conference and tele-robotic surgery. It requires
the presence of both parties at the same time and a telecommunication link between
them that allows a real-time interaction to take place. Video-conferencing equipment is
one of the most common forms of technology used in synchronous telemedicine.

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  Store-and-forward telemedicine or Asynchronous: It involves acquiring medical data
(like medical history, images, etc) and then transmitting this data to a doctor or medical
specialist at a convenient time later for assessment offline. It does not require the
presence of both parties at the same time. Examples are tele-pathology, tele-radiology,
and tele-dermatology.

TYPES OF CONNECTIVITY: Telemedicine Technology - Evolution

 Point to Point System - In networking, the Point-to-Point Protocol (PPP), is a data link
protocol commonly used to establish a direct connection between two nodes over
terrestrial and satellite link e.g. SGPGIMS, Lucknow is connected to the medical
colleges of Orissa through point to point connectivity via satellite link and District
Hospital, Rae Bareli via fiber optic cable network, One patient end connect to One
Specialist Doctor within the hospital.

 Point to Multi Point System - is a term that is used in the telecommunication field
which refers to communication which is accomplished via a specific and distinct type of
multipoint connection, providing multiple paths from a single location to multiple
locations e.g. two District Hospitals of Uttaranchal state are linked to SGPGIMS via
ISDN link, One patient end at a time connect to any of the specialist Doctors’ end within
the hospital.

 Multi Point to Multi Point System - Several patients’ end simultaneously connects to
different Doctors’ end at different hospitals at different geographical locations.

Major areas of Telemedicine Technology Adopted…

 Tele-consultation, Tele-diagnosis & Tele-treatment- The patient with the local doctor
consults the specialist, obtains the line of treatment.
 Tele-education & Tele-training - For Continuing Medical Education, Training for doctors &
paramedics from a higher level Hospital/Institution.
 Tele-monitoring - Regular monitoring for intensive care & emergency care.
 Tele-support - Support during disaster management.

TECHNOLOGY OF TELEMEDICINE
 The concept of telemedicine was introduced more than 30 years ago through the use of
telephone, facsimile machine, and slow-scan images. However, the enabling technology
has grown considerably in the past decade.
 Telemedicine is a confluence of Communication Technology, Information
Technology, Biomedical Engineering and Medical Science. The Telemedicine system
consists of customised hardware and software at both the Patient and Specialist doctor
ends with some of the Diagnostic Equipments like ECG, X-ray and pathology
Microscope/Camera provided at the patient end. They are connected through a Very Small
Aperture Terminal (VSAT) system and controlled by the Network Hub Station of ISRO.
Through a Telemedicine system consisting of simple computer with communication
systems, the medical images and other information pertaining to the patients can be

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 sent to the specialist doctors, either in advance or on a real time basis through the satellite
link in the form of Digital Data Packets.
 These packets are received at the specialist centre, the images and other information is
reconstructed so that the specialist doctor can study the data, perform diagnosis, interact with
the patient and suggest the appropriate treatment during a Video Conference with the
patient end. Telemedicine facility thus enables the specialist doctor and the patient
separated by thousands of kilometers to see visually and talk to each other. This enables
the specialist doctor to assess the physical and psychological state of the patient
and suggest treatment.
 This remote tele-consultation and treatment is much more valuable in case of post
operation (Post Surgery) follow up since the patient is not required to travel unnecessarily
and hence saving money and time. In this way, the systematic application of
Information and Communication Technologies to the practice of healthcare rapidly
expands the outreach of the healthcare system.

COMPONENT OF TYPICAL TELEMEDICINE

 Imaging work station or specialized software for imaging.
 Video conferencing equipment (This will include minimum standards for video
conferencing system, including data rate, picture resolution, frame rate, type of camera,
audio quality etc.).
 Digital camera or scanner or digitizer for x-ray, CT scan and MRI images.
 Communication media like ISDN (Integrated Services Digital Network), Internet and
V-SAT.

TELEMEDICINE APPLICATION
 Remote consultation and critical care monitoring.
 Disease surveillance and programme tracking.
 Continuing Medical Education and public awareness
 Disaster management
 Disease management
 Home care and ambulatory monitoring
 Robotics surgery.

ADVANTAGES OF TELEMEDICINE
 Eliminate distance barriers and improve access to quality health services.
 In emergency and critical care situations where moving a patient may be undesirable
and/or not feasible.
 Facilitate patients and rural practitioners’ access to specialist health services and
support.
 Lessen the inconvenience and/or cost of patient transfers.
 Reduce unnecessary travel time for health professionals.
 Reduce isolation of rural practice by upgrading their knowledge through tele-education
or tele-CME.

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  Telemedicine can be used as a teaching tool, by which experienced medical staff can
observe, show and instruct medical staff in another location, more effective or faster
examination techniques.

BARRIERS IN TELEMEDICINE PRACTICE

More and more doctors and patients are resorting to the use of telemedicine due to its
advantages of convenience and cost-saving. The practice of telemedicine, however, has
brought with it several complicated issues. These issues involve not only healthcare
workers and consumers but the society, technologists and the lawmakers also. Those
interested in the specialty of telemedicine need to address these issues.

 Physician/Patient Acceptance - Physicians and patients have unique technological

resources available to improve the patient-physician relationship. It has been found that
patients have no difficulty in accepting telemedicine program.

 Availability of Technology at a Reasonable Cost:

 Accessibility:
 Reliability: Telemedicine systems to follow relevant reliability standards of
equipment/systems of similar category to ensure availability of service with minimum
system downtime.
 Funding/ Reimbursement Issues:
 Lack of Trained Manpower:
 Legal & Ethical: Telemedicine technology has been proved and established and its
advantages and benefits are well known but still many healthcare professionals are
reluctant to engage in such practices due to unresolved legal and ethical concerns. In
case of a cross-border tele-consultation which country’s litigation laws will be applied in
case– those of the country in which the patient is living or those of the remote
physician?
 Privacy and Security Concerns:
 Rural Telemedicine Network -The uses of Telemedicine are limited Only by our
imagination. Healthcare in Rural India 70 % of India’s population live in rural areas 90%
of secondary & tertiary care facility are in cities and towns Low penetration of healthcare
services. Lack of investment in health care in rural areas specially the specialist doctors
Rural & remote areas continue to suffer from absence of quality healthcare services.

Telemedicine Standardization -NEED

 Large number of Telemedicine Networks being installed in the county.
 Lack of uniform, multipurpose, telemedicine standards meeting needs of diverse used
groups at different hierarchical levels hamper effective use of telemedicine.
 To promote the growth of Telemedicine.
 To Increase availability of quality medical service to those in need.
 To Improve quality of medical services, as it facilitates access to expert opinion leading
to better diagnosis, treatment and prognosis.

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 To define usage of Telemedicine technology that is appropriate to the Indian
environment.
 To identify the mechanisms for protecting the privacy & confidentiality of individuals’
health data.
 To define processes for scientific practice of Telemedicine.
 To contribute to broad international cooperation in the scientific, legal and ethical
aspects of the use of Telemedicine.
 To encourage continued support for the advancement of Telemedicine and its
applications globally to keep the standards contemporary.
 To provide a framework for interoperability and scalability across Telemedicine services
within the country and outside.

 Telemedicine Systems are interoperable(Develop telemedicine networks that

interface together and create an open environment sharing the application on different
participating systems in real-time or seamless interface between several applications ).
 Compability – (Equipment/systems of different vendors and different versions of the
same system, to be able to be interconnected ) with new version of technology.
 Scalability – (Equipment/systems inducted for telemedicine to be able to be augmented
with additional features and functions as modular add-on options. ) of systems without
total replacement while expanding capability.

Recommended Guidelines and standards for Telemedicine

Vision : Defining a National Telemedicine Network
 Vision for National Telemedicine Network to cover large population. A three tier
hierarchical connectivity structure can be contemplated for implementation in phases to
include:
 A Primary Health Centre (PHC) / Community Health Centre connected to District level
hospital.
 A District level Hospital connected to a State Level Hospital / Selected Specialty
Hospital State Hospitals and selective District hospitals being connected to a super
specialty hospital at the National level.

National / International e-health Projects under planning / implementation

Ministry of Health & FW Project, Govt. of India
 Integrated Disease Surveillance Project.
 Tele-opthalmology project.
 National Telemedicine Grid.
 National onconet Project (cancer care delivery programme).
 National Medical College Network.
 National Digital Medical Library Consortium.
 Vaccination Schedule.
 Maternity Care.
 Family Planning.
 Medicines.
 Ambulances Services and Transportation.
 Blood Bank, Life Saving Drugs.
 Doctor’s Database,Appointment with Doctors etc.
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THE EVOLUTION OF TELEMEDICINE IN INDIA
Telemedicine in India provides insight into the growing telemedicine market in India.
With a rural population nearing 700 million. With every sixth individual on the planet living in
India, the Indian healthcare industry is one of the biggest. In the last six years, thanks to
the relentless work done by several groups of committed champions of telemedicine
including Apollo Hospital.

 The Indian Space Research Organization (ISRO).

 SGPGIMS in Lucknow ( Sanjaygandhi postgraduate institute of medical sciences).
 SRMC (Sri Ramachandra Medical College) in Chennai.
 AIMS in Kochi (All India Medical Science).
 Narayana Hrudayalaya in Bangalore.
 The Apollo Hospital Group has networked dozens of remote rural hospitals providing
digital connections to one of its main facilities in.

 AIIMS New Delhi and PGIMER (Post Graduate Institute of Medical Education Research)
Chandigarh.

The teledensity of India (The Indian telecommunications industry is the world's fastest
growing telecommunications industry) in 2007 will be 22% with an expected almost four
fold increase of mobile phones over land lines.

The Government of India is embarking on a major e-governance project with 110,000

multipurpose internet kiosks in villages. (A telecentre is a public place where people can
access computers, the Internet, and other digital technologies that enable them to gather
information, create, learn, and communicate with others while they develop essential digital
skills by a different name: public internet access center (PIAP), village knowledge center,
info center, community technology center (CTC), community multimedia center (CMC),
multipurpose community telecentre (MCT), Common/Citizen Service Centre (CSC), school-
based telecentre, etc).Tele education for medical personnel has taken off in a big way.
The Ministry of Information Technology has drawn up standards on telemedicine and these
will eventually be implemented. Preliminary information is being gathered regarding the
feasibility of launching a HEALTHSAT (“HEALTHSAT”, an exclusive satellite for meeting the
healthcare and medical education needs of the country at large).

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 BIBLIOGRAPHY.

 Basvanthappa.B.T. “Nursing Administration.” 2nd Ed.Jaypee Brothers Medical

publication. Delhi. Pp.689 695.

 Gulani.Krishna Kumari”community Health Nursing Preinciple & practices.”

1st Ed.2008. Kumar publishing house. Delhi pp.520,639,654,655.

 Kamalam. S. “Essential in Community Health Nursing practice.”1st Ed. Jaypee

Brothrs Medical Publication pvt. Ltd. Delhi. Pp352 370.

 Park. K.”Preventive and social Medicine .” 20th Ed.Banarasidas Bhanot.

Jabalpur.2009.pp758 759.

Internet

 Telemedicine 101: Telemedicine Coming of Age - Telemedicine 101: Telemedicine

Coming of Age, by Nancy Brown

 http://www.advcomms.co.uk/telemedicine/definition.htm

 http://www.medterms.com/script/main/art.asp?articlekey=33620

 <http://202.83.164.29/egdsite04/?p=projimpu>

 <http://www.psych.org/Departments/HSF/UnderservedClearinghouse/Linkeddocuments/
telepsychiatry.aspx>

 ^ http://www.americantelemed.org/files/public/abouttelemedicine/What_Is_Telemedicine
.pdf

 ^ W. John Blyth. "Telecommunications, Concepts, Development, and Management",

Second Edition, Glencoe/McCgraw-Hill Company,1990, pp.280-282.

 ^ Microsoft PowerPoint - TELECARDIOLOGY AND.ppt [Compatibility Mode]

 ^ Teletransmission of ECG Waveform: An ingenious low priced technique - Indian heart

journal Vol.34 No.6, 1982
 http/www.mit gov in.

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 In TCP/IP a loopback device is a virtual network interface implemented in software
only and not connected to any hardware, but which is fully integrated into the computer
system's internal network infrastructure. Any traffic that a computer program sends to the
loopback interface is immediately received on the same interface.

 Correspondingly, the Internet Protocol (IP) specifies a loopback network.

The Internet Protocol (IP) is the principal communications protocol used for
relaying datagrams(packets) across an internetwork using the Internet Protocol Suite.
Responsible for routing packets across network boundaries, it is the primary protocol that
establishes the Internet.

Telecommunications

In telecommunications, loopback, (short loop) is a hardware or software method which

feeds a received signal or data back to the sender. It is used as an aid in debugging
physical connection problems. As a test, many data communication devices can be
configured to send specific patterns (such as all ones) on an interface, and can detect the
reception of this signal on the same port. This is called a loopback test and can be
performed within a modem or transceiver by connecting its output to its own input. A circuit
between two points in different locations may be tested by applying a test signal on
the circuit in one location, and having the network device at the other location send a signal
back through the circuit. If this device receives its own signal back, this proves that the
circuit is functioning.

A hardware loop is a simple device that physically connects the receive channel to
the transmit channel. In the case of a network termination connector such as X.21, this is
typically done by simply connecting the pins together in the connector. Media such
as optical fiber or coaxial cable, which have separate transmit and receive connectors, can
simply be looped together with a single strand of the appropriate medium.

A modem can be configured to loop incoming signals from either the remote modem or the
local terminal. This is referred to as loopback or software loop.

From smoke signals to satellites

Long before the invention of phones or even mobile phones, smoke signals
were used to communicate messages over a long distance. Story has it that
African villagers used smoke signals to warn people to stay away from the
village in case of serious disease. Modern technology has refined the
communication over long distances – enabling the use of modern medicine in
remote and poor areas.

Nayana (which means 'eye') - a diabetes retinopathy prevention and treatment van - is a
venture funded by the World Diabetes Foundation(WDF) in Karnataka state and is indeed a
great boon for the rural people living with diabetes retinopathy. Three year ago when the
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van was first introduced in this area retinopathy treatment was only been available at
certain urban hospitals. This means traveling 200-300 Km to access such care, resulting in
huge barrier for people who live in rural areas and semi-urban areas. However, now
Karnataka has achieved impressive results after introducing a unique to bring the treatment
out the patients.

Every month the van visits 23 locations across 13 districts catering to the needs of 18.31
million people. These locations consist Of 8 Eye Hospitals/Eye Departments Of larger
hospitals, 3 Government hospitals and 11 other clinics.

Thus 87.7% of the total population of these villages has been screened within a period of
one and a half years. Just for the sake of figures, 970 people had known diabetes and 1114
persons were diagnosed for the first time. 1061 retinal examinations have been done in the
telemedicine van. Those identified to have sight threatening diabetic retinopathy are treated
free of cost at the main centre. Medicines are not provided free, except in very special
cases of type 1 diabetes. But tests and specialized treatments are free. Thus effective
strategies in community based diabetic screening programmes in a rural setting have been
evolved by involving ophthalmologists of urban areas via telemedicine.

There are several negative aspects of telemedicine and the first one is the cost. Many
industry experts believe that it is more cost effective however the fact of the matter is that
as of now it is very expensive. The usage of telemedicine depends on several outside
factors that are not in the control of the medical industry nor the user itself.

Why are Telemedicine and Telehealth so Important in Our Healthcare System?

Telemedicine is emerging as a critical component of the healthcare crisis solution.
Telemedicine holds the promise to significantly impact some of the most challenging
problems of our current healthcare system: access to care, cost effective delivery, and
distribution of limited providers. Telemedicine can change the current paradigm of care and
allow for improved access and improved health outcomes in cost effective ways.
Telemedicine increases access to healthcare:
Remote patients can more easily obtain clinical services.
Remote hospitals can provide emergency and intensive care services.
Telemedicine improves health outcomes:
Patients diagnosed and treated earlier often have improved outcomes and less costly
treatments.
Patients with telemedicine supported ICU's have substantially reduced mortality rates,
reduced complications, and reduced hospital stays.
Telemedicine reduces healthcare costs:
Home monitoring programs can reduce high cost hospital visits.
High cost patient transfers for stroke and other emergencies are reduced.

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Telemedicine assists in addressing shortages and misdistribution of healthcare
providers:
Specialists can serve more patients using telemedicine.
Nursing shortages can be addressed using telemedicine.
Telemedicine supports clinical education programs:
Rural clinicians can more easily obtain continuing education.
Rural clinicians can more easily consult with specialists.
Telemedicine improves support for patients and families:
Patients can stay in their local communities and, when hospitalized away from home, can
keep in contact with family and friends.
Many Telehealth applications empower patients to play an active role in their healthcare.
Telemedicine helps the environment:
Reducing extended travel to obtain necessary care reduces the related carbon footprint.
Telemedicine improves organizational productivity:
Employees can avoid absences from work when Telehealth services are available on site or
when employees can remotely participate in consultations about family members.
These examples illustrate the some improved outcomes and cost savings being
achieved by telemedicine and Telehealth programs:
Home monitoring of chronic diseases is reducing hospital visits by as much as 50% by
keeping patients stable through daily monitoring.
The national average for re-admission to hospitals within 30 days following a heart failure
episode is 20%. Telehealth monitoring programs have reduced that level to less than 4%.
Timely provisions of treatments that effectively reverse the consequences of a stroke have
risen from 15% to 85% due to the availability of telestroke programs.
Telemedicine support to Intensive Care Units (often called eICUs) is reducing mortality
rates by 15 - 30% and substantially reducing complications and length of stay.
Telemedicine retinopathy screening programs support early identification of serious eye
disease and reduce the incidence of blindness in diabetic patients.

What is the Difference between Telemedicine and Telehealth?

Telehealth refers to a broader scope of services that includes telemedicine, but also
includes other services that can be provided remotely using communication technologies.
The federal Office for the Advancement of Telehealth, describes Telehealth as including
telemedicine and a variety of other services.

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