CHAPTER I

INTRODUCTION

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 CHAPTER I

1.INTRODUCTION

The institution of medicine defines telemedicine as the use of electronic information and
communications to provide and support health care when distance separates the participants.
The most common applications today are in transmission of high-resolution X-rays, cardiology,
orthopedics, dermatology and psychiatry. Often, interactive video and audio are used for patient
consultations and guidance on procedures, sometimes video briefings and records of specific
operations are kept on a network in digital form. Groups of physicians, teachers and researchers of
ten meet across large distances. Telemedicine also embraces the management of electronic patient
records, access to libraries and databases on the web and on the private networks, and excessive use
of e-mail by many in the medical profession.
Telemedicine arose originally to serve rural populations, or any people who are geographically
dispersed – where time and the cost of travel make access to the best medical care difficult. Now, it
is increasingly being used in mainstream medicine, tom allow doctors of the world to share
expensive resources and valuable opinion.
Telemedicine is increasingly global in its reach, in 1997 there were 188 active programs around the
world, including Israel, Chile, India, Taiwan, Japan and the U.S.A.The availability of telemedicine
is dependent to a large degree on telecommunications, and on high bandwidth; the field is
concerned with advanced telecom equipment and standards, methods of increasing effective
bandwidth and network performance, costs of installations and operation, security, confidentially
and reliability, and the government legislation aimed at furthering the progress in these areas.
The importance of bandwidth can be seen in an example. With a 28.8 kbps dial-up connection,
transmission of a standard X-ray takes 30 minutes, with a t1 line at 1.5 Mbps it takes 30 seconds,
with a high speed DS3 circuit, it takes 1 second. Clearly, productivity and usability of telemedicine
data depends on availability of high bandwidth.

1.1Introduction to Telemedicine System

The earliest example of telemedicine was in the physiological monitoring of the astronauts through
pioneering work done by N.A.S.A. The Gemini and Apollo astronauts in the 1960‘s had two-way
video connections with space medical experts in Houston, and developed a quite natural mode of
interaction from orbit that featured taking care of routine health questions and needs, and early
experiments of weightlessness. This was followed by trials at Boston‘s Logan airport, and
participation by native American reservations in the STARPHAC program.

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Since then, this technique of telemedicine has started and has benefited lots of people all over the
world.

Father of Telemedicine

DR. Jay H. Sanders, MD, FACP, FACAAI

President and Chief Executive Officer The Global Telemedicine Group

DR. Jay H. Sanders, M.D., is the CEO of The Global Telemedicine Group, Professor of Medicine
(Adjunct) at Johns Hopkins School of Medicine and a Founding Board Member and President
Emeritus of the American Telemedicine Association. Known to many as the "Father of
Telemedicine,"
He developed the first state-wide telemedicine system & the first Correctional telemedicine
program; the first tele-homecare technology, called "The Electronic House Call"; and the first
telemedicine kiosk. His consulting activities have included NASA, DOD, HHS, the FCC, State
Governments, WHO, and multiple academic institutions and Fortune 500 companies.

In 1994, he introduced telemedicine capability to the then Assistant Secretary of Defence (Health
Affairs), Dr. Steven C Joseph; that culminated in the initiation of the use of this technology within
DOD. He was subsequently asked to serve as the sole civilian representative on the DOD
Telemedicine Board of Directors with the Surgeons General of the Army, Navy and Air Force.

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1.2 History of telemedicine

Fig.no.1.2.1: History of telemedicine

Telemedicine, you might be surprised to learn, was practiced in ancient times. The history of
telemedicine closely parallels the history of communication and information technologies. The key
technical feature of telemedicine is being able to communicate medical data over a distance, and
long distance communication methods existed throughout human history.

Some forms of medical information can be communicated over distance just easily as any other
verbal information. (Or, depending on your outlook and the age of the technology involved, they
can be communicated with the same level of difficulty.) In the past, information that a new
sovereign was crowned can be sent over the same long-distance communication medium as a
warning about a dangerous disease outbreak. Here are a couple additional telemedicine examples
that only require verbal communication:

 Identification, or diagnosis, of a specific disease based on a verbal description of the

symptoms
 Prescription for the patient regarding what to eat and drink

In this article, we walk through telemedicine history until the present time.

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Ancient Telemedicine

We’ll start the times of ancient Greece and Rome, around 500 BCE. By this point in human history,
humans have mastered agriculture and lived in multiple nearby villages or towns. Communication
between towns was common. Human messengers, of course, could still be used to transfer medical
advice or medicine. In addition, additional methods of long distance communication became widely
adopted.

The major driver for improvements in long distance communication was the military. Cities needed
to know as quickly as possible whether a foreign army was approaching, and be able to coordinate
their own forces from a distance. Any other communication needs, medical or otherwise, were
lower priority. Several widely used communication mediums included:

 Fires
 Smoke signals
 Light reflection beacons
 Drums
 Horns

Around the same historical time, we have evidence that some of these communication mediums,
specifically smoke signals and light reflection, were used to communicate medical information.
Specifically, long distance communication methods were used to signal the outbreaks of plagues
and to notify about health events such as births or deaths. Similarly, just like in ancient Greece,
American Indian tribes also used smoke signals to relay medical calamities and health events.

Early Telemedicine

The history of modern telemedicine, as we know it, was kicked off by the inventions of the
electrical telegraph and the telephone. Although other inventions, such as flag semaphores and light
telegraph, came onto the scene earlier, they were primarily used for military and naval
communication. Before the telegraph and telephone, communication inventions did not expand the
scope of telemedicine beyond ancient times. Mail, another popular long-distance communication
medium, was used for medical communication. However, from a technological perspective, mail
can be considered simply an extension of the human messenger.

The telegraph and telephone brought long distance communication into the mainstream, where
almost anyone could send a telegraph message or make a phone call. Telegraph was still a special-

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use technology — few individuals installed telegraphs in their homes due to the special training
required to operate the telegraph, as well as due to the lack of a sufficient network of other
telegraph receivers. Nevertheless, thanks to the communication speed of the telegraph, this
technology was adopted for telemedicine in military situations. During the U.S. Civil War,
telegraph was used for ordering medical supplies as well as communicating deaths and injuries on
the battlefield.It seems likely that telegraph was also used for medical consultations.

With the telephone, the era of the connected world arrived. Major city hospitals and doctor offices
installed telephones. Within a few years, many city residents also had telephones in their homes. All
of a sudden physicians could talk over the telephone to their patients and give medical advice
directly. In addition, medical providers could speak over the phone to other physicians in order to
consult or exchange information.

All of us, the children of the modern world, take the telephone for granted. We’ve seen and used
telephones from our childhood. Many people do not consciously consider the use of telephone as a
telemedicine application. Patients don’t consider it out of the ordinary when they discuss their blood
test results with a nurse over the phone. In fact, the use of the telephone is on the decline. Many
people now prefer other asynchronous communication methods, such as text messages, which are
more convenient for them. Still, the fact remains that the telephone was the foundation for many
later communication and telemedicine technologies.

Through the 1900s, the overall usage of the telephone grew as the telephone network was enhanced
with higher quality signals, telephone numbers, and other features. In 1968, 9-1-1 became the
official emergency telephone number in the United States. The number could be used to report a
fire, get the police, or a medical emergency. Previously, people using the telephone had to get the
operator to forward their call to the right department (police, fire station, or hospital), or to know the
specific number to dial. From a telemedicine perspective, 9-1-1 provided a consistent and faster
access to emergency medical care.

Telefax, although invented before the telephone (and known as electric printing telegraph), did not
gain significant traction until fax devices began to use common telephone lines and telephone
numbers for transmissions. To this day, medical professionals use faxes en masse to transmit
medical records.

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Rise of Telemedicine

The first idea of telemedicine as we know it today appeared in the April 1924 issue of Radio News
magazine. The magazine depicted using television and microphone for a patient to communicate
with a doctor, including use of heartbeat and temperature indicators. The concept was an
imagination of the future, as U.S. residents did not yet have televisions in their homes, and radio
adoption was just gaining steam.

Proposals to transmit stethoscope readings and other instrument data over existing communication
channels (telephone, radio, etc.) have been made in the first half of the 1900s. However, none of
these one-off experiments picked up any traction.

The first uses of telemedicine to transmit video, images, and complex medical data occurred in the
late 1950s and early 1960s. In 1959, the University of Nebraska used interactive telemedicine to
transmit neurological examinations, which is widely considered the first case of a real-time video
telemedicine consultation. Other programs followed, often implemented in an academic setting,
which focused on transmission of medical data such as fluoroscopy images, x-rays, stethoscope
sound, and electrocardiograms (ECGs). The main motivations of these early projects were:

      Providing access to health care in rural areas

      Urban medical emergency situations

A major break for the progress of telemedicine came in the 1960s when several partners, including
the National Aeronautics and Space Administration (NASA), Lockheed Corporation, and U.S.
Indian Health Service, joined together to work on STARPAHC project. STARPAHC stands for
Space Technology Applied to Rural Papago Advanced Health Care. The project provided
telemedicine access to an American Indian reservation using the same technologies intended for
astronauts on space missions.

Many additional grant and government-supported telemedicine initiatives followed, including:

      Providing medical care in a war zone

      Providing medical care to remote scientific stations in Arctic and Antarctic
      Providing medical care to correctional facilities without transporting inmates to the
hospital
      Digital transmission of radiology images

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Radiology was the first medical specialty to fully embrace telemedicine. With the help from grant-
sponsored projects, which proved the reliability and efficiency of telemedicine, the medical
community gained confidence in teleradiology. In 1980s some radiologists began to use
teleradiology systems to receive images for telemedicine consultations.

In almost all of the early deployments of telemedicine, the telemedicine projects were large
undertakings requiring considerable staff and organizational changes. The telemedicine
implementations used custom hardware and software equipment, often specifically created for the
specific use case. The equipment was bulky and required specially trained personnel to use. This
means the average patient did not directly interact with telemedicine technologies. Instead, a
telepresenter handled the equipment and interacted with the patient. Due to the advancement of
technology and other factors, few early projects survived longer than 20 years in their original
forms.

We use the term Telemedicine 1.0 to refer to these early types of telemedicine deployments.
Specifically, these projects are characterized by the following:

      Custom, bulky hardware specifically created for telemedicine

      Designed for specific use cases, such as psychiatry consults in ER
      Expensive
      Requiring specially trained telepresenters

Early Fantasies
In the early 1900s, radio revolutionized communication. Inspired by radio’s sudden prominence in
every field from entertainment to national defense, it wasn’t long before innovators started
imagining how doctors could attend to patients over the radio. A Radio News Magazine from
1924 features an illustration of a doctor attending to a patient via video call, under the headline
“The Radio Doctor–Maybe!” At that point, this was only an editor’s vision of the future technology,
but 90 years later these dreams would be realized.

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1.3Objectives
 To improve patient outcomes.
 To increase patient engagement and satisfaction.
 To improve patient convenience.
 To provide remote and rural patients with access to care.
 To improve leverage of limited physician resources.
 To reduce cost of care delivery.
 To reduce hospital readmissions
 To reduce specialist efficiency
 To provide access to new specialties.
 To provide 24/7 access to specialists.
Other objectives include reducing emergency department overcrowding, increasing revenue and
supporting research or clinical trials.

1.4Types of Telemedicine
 Store-and –forward or asynchronous video.
 Remote patient monitoring (RPM).
 Mobile health or mHealth.
 Imaging services.
 Specialist and primary care consultations.

1. Live Video Conferencing

Fig.no.1.4.1: live video conferencing

Also known as synchronous video, live video conferencing is a live, two-way interaction between a
person & healthcare provider illness to determine if patient should proceed to an emergency room,
or to provide psychotherapy sessions.

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 2. Store & Forward (Asynchronous Video)

Fig.no1.4.2: store & forward

Store and forward is the transmission of recorded health history through an electronic
communications system to a healthcare provider who uses the information to treat the patient
outside of real time. This method is often used in rural areas between a primary care practitioner or
nurse practitioner who would like to consult with a specialist in another location.

3. Remote patient monitoring (RPM)

Fig.no.1.4.3: remote patient monitoring

RPM is the collection of personal health and medical data from a patient or resident in one location
that is then transferred electronically to a nurse, caregiver, or physician in a different location for
monitoring purposes. RPM is already being used to great extent in senior living in order to prevent
falls and monitor the vital health statistics of residents.
4. Mobile Health (M-Health)

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Fig.no.1.4.4: mobile health

M-Health uses mobile communications devices,

such as smartphones and tablet computers, and
hundreds of software applications for these
devices, which can do almost anything imagined
for supporting healthcare.

1.5 FUNCTIONS

 Video conferencing between patients and specialists doctors.

 Video conferencing between different specialists and other healthcare professionals.
 Monitoring patient vitals and statistics in ICUs.
 Security in data connection.
 Transfer of patients medical data among hospitals.
 Storage of information.

General architecture of telemedicine and its functionality

Telemedicine systems, in general, follow a hierarchical tiered structure which includes the
following:

Level 1: Local/remote telemedicine center. These are the local or primary healthcare unit
located in rural and remote areas.

Level 2: City/district hospital. Local/rural health centers are connected to the city/district
hospital. The district hospital, optionally, may further be connected to the state hospital.

Level 3: Speciality center. The city hospital is connected to the speciality centers for
disease-specific further assistance.

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 Fig.no.1.5.1: General architecture of telemedicine & it’s functionability

Fig.  presents a general architecture of a telemedicine system. A patient requiring medical

attention approaches the nearby local health center where a local health professional (may not be a
certified doctor) attends the patient and does the primary health check-up. This unit consists of basic
diagnostic equipment and tele-consultation devices linked via PC and Internet to the city hospital.
The primary responsibility of the local healthcare unit is to acquire all the vital statistics of the
patient in terms of physiological data (e.g., blood, urine, etc.) and images (e.g., ultrasound) and
transmits the data to the remote city hospital. After receiving the records, the remote medical
practitioner goes through every detail, before proceedings with live Interaction with patients. After
carefully examining the basic vital signs, the meeting is booked online between doctor and patient
at remote healthcare unit. The doctor makes use of an audio or video conferencing system as well as
automation live feeds to have live interaction with the patient. These remote hospitals are connected
to a centralized database where all the data of the patient as well as other details and even the
recorded audio/video interaction between doctor and patient are also stored. The stored information
can be accessed using mobile apps or web-based interface. The main hospitals are also linked to
specialist hospitals to provide specialized support to the patients in case of an emergency and these
specialized hospitals have same teleconferencing units enabled to support remote patients.
Technology at Work

In 1940s Pennsylvania, radiology images were sent 24 miles between two townships via telephone

line in the world’s first example of an electronic medical record transfer. A Canadian doctor built
upon this technology in the 1950s, constructing a teleradiology system that was used in and around

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Montreal. As these practices became more widespread, so did motion pictures, and with the advent
of modern film technology came serious plans for video medicine. The first people to use video
communication for medical purposes were clinicians at the University of Nebraska. In 1959, the
university established a two-way television setup to transmit information to medical students across
campus, and five years later linked with a state hospital to perform video consultations.
Today, telehealth technology serves many rural communities without local physician access,
and this was the basis behind the University of Nebraska’s research. In the early 1960s,
telemedicine appeared in urban communities as well, touching down in the world of emergency
medicine. The University of Miami School of Medicine partnered with the local fire department in
1967 to transmit electrocardiographic rhythms over radio to Jackson Memorial Hospital in rescue
situations. Remote medicine had officially hit the streets.

1.6 The Growth of Telemedicine

Telemedicine became popular in rural areas, where populations with limited healthcare access could
now reach specialists from afar. In the 1960’s and 70’s, the Public Health Department, NASA, the
Department of Defense and the U.S. Health and Human Services Department all invested time and
money for research in telemedicine.
One of the most successful of these government projects was the partnership between the Indian
Health Services and NASA. The project was called Space Technology Applied to Rural Papago
Advanced Health Care (STARPAHC), and provided both Native Americans on the Papago
Reservation in Arizona and astronauts in orbit with access to medical care. Microwave technology
transmitted X-ray photographs, electrocardiographs and other medical information to and from the
Public Health Service hospital.
Innovative projects like STARPAHC spurred research in the field of medical engineering, leading
to quick growth for telemedicine. Over the following decades, research in the field became popular
in universities, medical centers and research companies, with more creative, ambitious projects
following STARPAHC’s lead.

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1.7 Scenario in India

In India, the field of telemedicine is catching momentum nowadays as there are many hospitals
which are having their own telemedicine networks. Since last few years, in the metro cities, many
hospitals have launched their own telemedicine programmes and have been successful. Though in
India, perhaps the cost cannot be affordable but efforts are made to minimize the cost.

Also in certain hospitals they have telemedicine through satellite communication. Many hospitals in
the major cities have benefited the nearby rural areas and have been quite successful in helping the
villagers.

Also in some states there are ISDN networks to provide telemedicine. In coming years, many
hospitals claim to provide a telemedicine in various parts of the country. Also due to possibility of
fibre – optic cables, the internet based telemedicine would be the best form of communication as far
as the cost initial expenditure and the quality is concerned.
Telemedicine-India’s Option or Necessity

 India characterized by low penetration of healthcare services

 90% of secondary & tertiary healthcare facilities in cities and towns away from rural India
where
68% of population lives
 Primary health care facilities for rural population highly inadequate
 Despite several initiatives by Government & private sector the rural and remote areas continue
to
suffer from absence of quality healthcare
 Significant proportion of patients in remote locations could be successfully managed locally
with
Advice/ guidance from specialists/super-specialists in cities, without having to travel to the
specialists.

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Telemedicine in Kerala

• Setting up of Telemedicine & Telehealth Education facilities in Kerala using the Technology
developed under DIT
– The project will link three specialty medical hospitals at MCH,SCTIMST& the RCC, with 4
District/ Rural Hospitals.
– Continuing Medical Education (CME)
• Cance rNet: Telemedicine system for Cancer Patients in Kerala
– Establishment of an Oncology Network for providing Telemedicine services
• Cancer detection, treatment, pain relief ,patient follow-up and continuity of care
in peripheral hospitals(nodal centers) of Regional Cancer Centre (RCC) implemented by C-
DAC, Trivandrum and RCC which
– Connects RCC, Trivandrum and five nodal outreach centers'
– More than 3000 patients treated/consulted at these nodal centers'
– Major financial benefit to patients

Telemedicine System in West Bengal

Telemedicine for Tropical Diseases

– Utilizes Technology developed by WEBEL & IIT Kharagpur
• Tele-medicine for diagnosis & Monitoring of tropical diseases in West Bengal
• Uses low speed POTS connectivity
• Diagnosis and monitoring of skin and blood related tropical diseases
• The system has been installed in School of Tropical Medicine , Kolkata and two District
Hospitals
• More than 800 patients undergone consultations
– Being upgraded & extended to cover two referral hospitals and four District hospitals
• Will use 512 KBPS leased line and the West Bengal State Wide Area Network optical link of
2Mbps

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Telemedicine in North East States

– Need: the area is very remote and lacks Specialty Healthcare

– Kohima – Turnkey Project
• Implementation of Telemedicine Solution at Kohima Hospital in Nagaland
• Partnership between Govt. of Nagaland, Marubeni India Ltd, Apollo and Ministry of
Communications and Information Technology
– Setting up of two telemedicine centers connecting hospitals in capitals of the North-eastern
states of Sikkim & Tripura with super-specialty hospital under Community Information Centre
scheme of DIT
– Major scheme is planned by North Eastern Council of India to cover all 75 districts
in seven states through Telemedicine

Telemedicine Standardization

 Need:
Large number of Telemedicine networks being installed in the country
Lack of uniform, multipurpose telemedicine standards meeting needs of diverse user groups at
different
hierarchical levels hamper effective use of telemedicine
 Adherence/adoption to standards ensures Telemedicine Systems are interoperable
Compatibility with new version of technology scalability of systems without total replacement while
expanding capability
Recommended Guidelines and standards for Telemedicine
 Technology & Practice in India evolved under a high level committee.

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1.8 Features of Internet / Intranet based Telemedicine

In India, the field of telemedicine is catching momentum nowadays as there are many hospitals which
are having their own telemedicine networks. Since last few years, in the metro cities, many hospitals
have launched their own telemedicine programmes and have been successful. Though in India, perhaps
the cost cannot be affordable but efforts are made to minimize the cost.

Also in certain hospitals they have telemedicine through satellite communication. Many hospitals in the
major cities have benefited the nearby rural areas and have been quite successful in helping the
villagers.

Also in some states there are ISDN networks to provide telemedicine. In coming years, many hospitals
claim to provide a telemedicine in various parts of the country. Also due to possibility of fibre – optic
cables, the internet based telemedicine would be the best form of communication as far as the cost
initial expenditure and the quality is concerned. allowed support for practically all information and
traffic needed for telemedicine, including:

      Patient education (text, images, video)

      Medical images such as x-rays and scans (DICOM image standards)
      Real-time audio and video consultation
      Vital signs and other body measurements (ECG, temperature, etc.

Globalization, content publishing, consumer demand, and other factors outside of health care drove

the Internet growth. This growth meant that considerable funds and engineering efforts went into
Internet infrastructure improvements, including:

      Communication speeds (bandwidth and latency)

      Information storage (databases, object-store for large files such as images and video)
      Availability – many web services employ back up servers, and even dynamically start up
additional servers if traffic increases
      Standard formats for data transmission (MP4, PNG, etc.)
      Security (encryption, password protection, access levels, etc.)

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       Application development — new programming languages (JavaScript), frameworks, and
open-source software (Apache)
      The Cloud – using virtual servers hosted by an infrastructure provider such as Amazon Web

Services (AWS)

      Digitizing information (digital cameras, scanners, etc.)

The above Internet improvements had a positive impact on health care and telemedicine. All of a
sudden it was easier and cheaper than ever to build a health care software application for exchanging
and storingclinical data, using the existing tools and frameworks for web applications.

The e-health floodgates opened with the transition to electronic medical records (EMRs), led by U.S.
government incentives (and future penalties). Most of today’s modern EMR vendors employ the
Internet in order to provide access to medical information for medical providers and patients. In
addition, patient portals have become more common, where patients can look up their lab results, refill
prescriptions, or send a secure message to their physician.

Both medical providers and patients are becoming more and more technology savvy.  The use of the
Internet is now common place in health care it is surprising to hear of a private practice without a web
site. Many practices are trying to leverage the Internet further by engaging existing and potential new
patients through social media outlets like Twitter and Facebook. Also, they reach out to their patients
and encourage them to post reviews on Yelp and other web sites.

Patients, meanwhile, have access to tons of medical information online. Many patients research their
symptoms using “doctor Google” before coming to see their physician. Of course, one issue with
getting information from public sources on the Internet is reliability – some online articles may mislead
or confuse patients.

Today, the Internet is firmly established in day-to-day life. The majority of U.S. adults own a mobile
device capable of accessing the Internet, such as a smart-phone or tablet. Many rely on these devices as
their primary entry point for the online world.

The ubiquity of the Internet, the ready access to Internet-enabled computing devices, and the technical
savvy of the U.S. population are important factors in the ongoing Telemedicine 2.0 transition. The

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“2.0” suffix typically refers to applications running on Web 2.0 technologies, and characterized by their
collaboration, usability, interoperation, and openness features. This moniker is commonly used in
health care in terms such as Health 2.0 or Medicine 2.0. Telemedicine 2.0 is characterized as:

      Using existing computing device belonging to patient or physician

      Communicating over the Internet and using standard web infrastructure
      Using inexpensive off-the shelf equipment for gathering clinical data
      Easy to use — can be used directly by patient or physician without special training

Some of the affordable measurement devices that are commonly used with telemedicine include:

      Smartphone cameras
      Digital stethoscopes
      Ophthalmoscopes (for eye exams)
      Otoscopes (for ear exams)
      Vital sign monitoring devices
      Wearable biosensors Telemedicine has now fully embraced the Internet communication
medium. Many private practices and health care systems are in the process of becoming hybrid
health care providers – allowing patients to see their medical provider either through
telemedicine or in-person. We take a deeper look at the categories and types of Telemedicine
2.0 use cases in the Categories of Telemedicine article.

In India, the field of telemedicine is catching momentum nowadays as there are many hospitals which
are having their own telemedicine networks. Since last few years, in the metro cities, many hospitals
have launched their own telemedicine programmes and have been successful. Though in India, perhaps
the cost cannot be affordable but efforts are made to minimize the cost.
Also in certain hospitals they have telemedicine through satellite communication. Many hospitals in the
major cities have benefited the nearby rural areas and have been quite successful in helping the
villagers.
Also in some states there are ISDN networks to provide telemedicine. In coming years, many hospitals
claim to provide a telemedicine in various parts of the country. Also due to possibility of fibre – optic
cables, the internet based telemedicine would be the best form of communication as far as the cost

20
initial expenditure and the quality is concerned.

CHAPTER II

MEDIA
COMMUNICATION IN
TELEMEDECINE

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 CHAPTER II
2.MEDIA COMMUNICATION IN TELEMEDICINE

1. Telephone lines
2. ISDN lines
3. Satellite communication

A telemedicine system‘s basic requirement is a good and sound communication medium, which will
provide an economical and reasonably good quality of data (especially images) at the receiver end. The
modern day Internet system provides an excellent medium for data communication.

2.1 Intranet
The concept of intranet in the development of a telemedicine network provides a very fast, easier and
error free data communication.
A dedicated network for the practice of telemedicine can be established between the city hospital and
other remote areas. A network in the form of different topologies can be designed as per the
requirement.
The most common topology in which it can be connected is either a client-server type or peer-to- peer
type of network.

2.2 Client – Server type network

In this type of networking, a server is placed at the main city hospital, which is connected to the remote
terminals through a telephone network, ISDN etc., a computer system and amodem.
Each terminal has a unique IP address which allows the clients to access the server. The servers are
again connected to a master or mainframe server, which will interconnect all theservers.
Thus a server can communicate to the other servers through the mainframe servers. Hence it is
basically a concept of wide area networks connected through either a PSTN or any other link.

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The exact topology can be easily explained by the following figure: -

HOSPITAL
SERVER

CLIENTCLIENT CLIENT MAIN

FRAME SERVER

HOSPITAL

SERVER

CLIENT
CLIENT CLIENT

Fig.no.2.1.1: Media communication in telemedicine

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 2.3 PEER-TO-PEER TYPE OF NETWORKING

This type of networking is used to communicate directly between server and client or client to
client (directly).
This type of network consists of an interconnection between server to clients and also directly
between clients.
The network can be developed using the telephone lines or ISDN etc, a computer system and a
modem. It can be designed according to the no. Of users and can be developed as a WAN. The
communication is generally through dial-up networking using modem and NETBEUI protocol.

The peer-to-peer networking topology can be shown by the following figure: -

HOSPITAL

SERVER

CLIENTCLIENTCLIENTCLIENTCLIENT

REMOTE PATIENTS

Fig.no.2.3.1: Peer to peer type of networking

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 2.4 TELEMEDICINE THROUGH WORLD WIDE WEB(INTERNET) 1
The basic Internet based telemedicine can be done through a computer system with a modem and an
Internet connection on both the ends.
6
The communication is the same as in the case of an Internet operation and hence is through telephone
lines.
The basic communication through the World Wide Web or the Internet is through the following ways: -

Through the e-mail and voice mail facility: -

E-mail facility can be used and a remote user can send e-mail to required doctor in a hospital through a
normal e-mail.
A normal written data can be typed and sent and an image can be scanned and compressed in a
standard format and then attached to the written data.
A voice-mail or a net to phone facility can also be availed of in the case of sending some type of sound
through the Internet or taking an oral opinion from the doctor.

Developing a website for a telemedicine facility: -

An innovative website can also be developed for a telemedicine programmed. With the help of this
website, one will be able to select a department and a particular expert from a group of departments and
experts.
Also the access becomes easier than the normal e-mail as the website is prepared to accept a particular
type of data or an image attachment and it would be easier for both the remote patient and a doctor to
communicate and exchange views and other written advices etc.
This website can also provide the facility of oral communication like the voice mail and also extended
techniques for transfer of sound (heart beats etc.) along with the written an image data.
All the above described techniques require only a computer system, modem, telephone lines, some
multimedia facility like speaker and microphone, scanner etc. at both the ends.
Thus due to minimum hardware involved it provides an economical way for telemedicine.

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 CHAPTER III
ADVANTAGES AND
DISADVANTAGES OF
TELEMEDICINE SYSTEM

26
 CHAPTER III

3. ADVANTAGES AND DISADVANTAGES OF

TELEMEDICINE SYSTEM

3.1 Advantages
Adopting the latest telemedicine initiatives can help your practice achieve numerous benefits. You can
lower healthcare costs, drive up practice efficiency and revenue, provide your patients better access to
healthcare services, and ultimately get happier, healthier patients who stay in your practice.
More Convenient and Accessible Patient Care
According to a recent Cisco global survey, 74% of patients prefer easy access to healthcare services
over in-person interactions with providers. In today‘s healthcare world, convenience is key. Adding
telehealth to your practice offers patients simple, on-demand care – without the usual wasted time and
cost of most in-person visits. Patients who live in remote locations, or who are homebound or just can‘t
take off time from work, can access care virtually. Video conferencing, smartphone apps, and online
management systems connect more patients with providers than ever before.

Healthcare Cost Savings

Remote analysis and monitoring services and electronic data storage significantly reduce healthcare
service costs, saving money for you, your patients, and insurance companies. Telemedicine also
reduces unnecessary non-urgent ER visits and eliminates transportation expenses for regular checkups.
Recently, the American Hospital Association reported on a telemedicine program that saved 11% in
costs and more than tripled ROI for investors. Beyond these general cost-savings, telehealth can help
boost doctors‘ revenue by turning on-call hours into billable time, attracting new patients, reducing no-
shows, and even reducing overhead for physicians who decide to switch to a flexible work-from-home
model for part of the week. Extended Specialist and Referring Physician Access With telehealth,
patients in rural or remote areas benefit from quicker and more convenient specialist access. In the
U.S., for every100,000rural patients, there are only 43 specialists available. These patients endure
longer appointment commutes and have trouble accessing lifesaving consultations for specific diseases
or chronic care plans. Telemedicine offers better access to more specialists. You can refer your patients
to the specific physicians they need, regardless of location. Or, if you‘re a specialist looking to expand
your patient population, telemedicine can help you reach a wider geographic region.

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Increased Patient Engagement

When patients are committed to their own healthcare goals, it leads to lower costs and improved health.
Engaging your patients through telemedicine can help them maintain appointments and care schedules.
Increased engagement initiatives can also curb obesity rates and tobacco use by helping you to
encourage your patients healthy lifestyle choices. Not only do virtual visits easier for them to reach out
with questions, report early warning signs, and make a follow-up appointment to make sure they‘re on
track.

Better Patient Care Quality

Telemedicine offers patient-centered approaches, such as improved timeliness of care. This is critical to
quality patient care. Patients can address healthcare issues quickly with real-time urgent care
consultations and learn about treatment options within minutes. A new study shows that telemedicine
patients score lower for depression, anxiety, and stress, and have 38% fewer hospital admissions.

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3.2 Disadvantages

While telemedicine promises to grow rapidly over the next decade and has clear benefits, it still poses
some technical and practical problems for healthcare providers.

Technical Training and Equipment

Restructuring IT staff responsibilities and purchasing equipment takes time and costs money. Training
is crucial to building an effective telemedicine program. Physicians, practice managers, and other
medical staff need to be trained on the new systems to ensure a solid ROI. In addition, your staffing
requirements may decrease. For instance, a nurse in a rural Alaska facility
can monitor up to 33 patients at once from a single location using telemedicine services.

Reduced Care Continuity

In cases where patients are using on-demand telemedicine services that connect them with a random
healthcare provider, care continuity suffers. A patient‘s primary care provider may not have access to
records from those other visits and end up with an incomplete history for the patient. Service provider
shuffling increases the risk that a doctor won‘t know a patient‘s history or have notes about care
routines. Because reduced care continuity can decrease care quality, consumer telemedicine providers
must apply sound data solutions to maintain adequate and accessible patient records. As more
healthcare providers adopt telehealth solutions to use with their own patients, care continuity will likely
increase, lessening the chance that patients end up at a retail clinic or urgent care center when they need
quick care.

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Fewer In-Person Consultations

Worried about technology‘s limitations? You‘re not alone. Many doctors worry about technical
problems associated with telemedicine. Senior Healthcare Group Consultant Arun Ravi told Becker’s
Hospital Review that poor broadband connections could lead to possible patient mismanagement Many
physicians and patients alike still like a personal touch, and not all procedures – even simple checkups
– can be performed digitally. However, in cases where patients just can‘t get in to see their doctors in-
person, and for many cases that don‘t require a physical exam, telehealth can be a good alternative.
 
.

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 CHAPTER IV

APPLICATION OF
TELEMEDICINE
SYSTEM

31
 CHAPTER IV
4.Application of Telemedicine System

4.1 Growth and Diversity

The number of telemedicine users is now expanding rapidly enough that no complete inventory of
applications is available, especially for projects involving private nonprofit and commercial
sponsorship or funding. To fill that information gap, a federal working group on telemedicine is
developing an inventory that will initially include government projects and then expand to
include state and private projects. Part of that effort has included a survey to identify rural
hospitals using telemedicine in one form or another. The Department of Defense and the
Department of Veterans Affairs are likewise working to document more fully telemedicine
activities at their facilities. Private organizations have also been tracking and reporting public and
private telemedicine programs. For example, the state health policy program of George
Washington University surveyed and analyzed state government initiatives to support
telemedicine as discussed further in Chapter 4 (Lipson and Henderson,1995).
Most tracking efforts focus on programs transmitting still images (e.g., radiologic images) or using
interactive television. One recent overview estimated that the number of programs using the latter
technology has reached 50, with growth doubling each year between 1990 and 1995 (Allen and
Perednia, 1996). The review also suggested that teleradiology installations were growing at a
similar pace, although getting accurate data on these programs has not been easy, in part because
vendors have been reluctant to release sales information (Franken,1996).

Fig.no.4.1.1: Growth & Diversity

32
4.2 Teleradiology

As indicated earlier, the most common current applications of telemedicine appear to involve
radiologic image transmission within and among health care organizations. Several steps are
typically involved in teleradiology including digitizing film images or directly producing digital
images, incorporating demographic and other patient information, compressing images (data) in
various ways to allow them to be sent more quickly and inexpensively, transmitting images
from one site to another, and reconstructing images for viewing and interpretation (Forsberg,
1995).

Additional steps are required for storing and retrieving images electronically.

The growth of teleradiology applications reflects several characteristics of radiology:

(a) its well-established consulting infrastructure based on mail and courier services;

(b) its early use of digital imaging technologies;

(c) the availability of Medicare payment for teleradiology consultations.

Radiology centers have long used mailed or courier-delivered films to provide, as described by
one organization, "consultation, second opinions, and primary interpretations; image over-read
for individuals getting started in MR [magnetic resonance imaging] or other difficult modalities;
quality control of image interpretation; vacation coverage; and additional coverage for groups
with an increasing case volume as yet insufficient to justify hiring an additional radiologist"
(UCSF, 1995). In many situations, teleradiology can make such distance services much quicker
and more convenient, and the electronic storage of images minimizes problems with mislaid or
lost films as images move between or within organizations. Radiologists can also have images
transmitted to home or office work stations so they may not have to go to the hospital to see
films when they are on call.

Fig.no 4.2.1: Teleradiology

33
4.3 Care in the Home and Other Non clinical Sites

The use of telemedicine in home and other nonclinical settings illustrates the significance of non video
means for providing information and advice and for monitoring patient status. The most familiar non
video telemedicine option is the use of the telephone. Physicians, nurses, and other personnel routinely
talk with patients and families providing information, checking their status, and offering reassurance
without the expense or inconvenience of an office visit for the patient or a home visit for the clinician.
To reduce avoidable office visits, many health plans have established telephone advisory programs,
staffed primarily by nurses, to provide patients with information, assessments, and recommendations
for routine medical problems. For medical and other emergencies, the 911 system works from any
telephone to put people in touch with dispatchers who assess the nature of the emergency, send medical
or other assistance as indicated, and provide medical instructions (e.g., for cardiopulmonary
resuscitation) when necessary.

34
CHAPTER V

CONCLUSION

35
 CHAPTER V

5. CONCLUSION

5.1 SUMMARISATION

The Chapter I is entitled “INTRODUCTION” contains the definition of telemedicine system,

various applications of telemedicine system and the need of telemedicine system in day to day life.
The scenario of telemedicine system is also described in this chapter. The features of internet based
Telemedicine system are explained in this chapter. Mainly it is the systems with the help of which one
can get medical help whenever and wherever it is required.
The Chapter II is entitled ―Media Communication in Telemedicine System‖, Contains
information about Intranet, client – server type network, Peer – peer connectivity and the Telemedicine
through world wide. All this types of network and connectivity are discussed here with various tree
diagrams.
The Chapter III is entitled as ―Advantages and Disadvantages of Telemedicine System‖, it
contains brief information advantages and disadvantages of the Telemedicine System. This Chapter
contains the information about why the Telemedicine System is important and why people should use
this technology.
The Chapter IV is entitled as―Applications Of Telemedicine System this chapter mainly
contain the information about the three main applications of the Telemedicine System i.e. Growth and
Diversity, Teleradiology and the Care in home and other Non-Clinical sites. The 1st part of this chapter
gives the brief information about growth in Telemedicine System in last few years. The 2nd part gives
the information about Teleradiology. The 3rd part gives the short information about how to monitor the
patients.
The Chapter V is entitled ―CONCLUSION which gives us the findings of our overall
study of the subject. In this Chapter, chapter wise summary is include for the ease of the reader and to
throw the light directly on the main topics which are discussed in the whole report. Nextly, by
conclusion the Chapter and the report is taken to end.

36
5.2 CONCLUSION

Telemedicine is the art of sending medical data, which includes previous histories, prescriptions, all
types of reports like X-rays, CT scan images, pathological reports etc. through a communication
system. It is the systems with the help of which one can get medical help whenever and wherever it is
required. This process would be very fruitful to the rural society who can remotely get opinion from the
expert doctors of the city. Even in the case of urban areas, the opinion the expert doctors in the other
cities or internationally reputed doctors can be sought. Thus, telemedicine is a boon for the ever-
advancing field of medicine.
The process of telemedicine commercially started with the usage of PSTN (Public switched telephone
network) i.e. the ordinary telephone network and some data communicating equipment. Now, in certain
advanced countries, it is done through fiber optic communication and wireless communication
techniques like wireless networking (WAN), VPN (Virtual private network), through satellite
communication i.e. VSAT networks etc. The most economical method of telemedicine is the
telemedicine through Internet, as it requires minimum hardware and a simple communicating medium
as compared to the other methods. Also nowadays due to the advancement in the networking
technology very fast and better resolution data communication is possible using high speed networks.
In this report we have discussed about the scenario of Telemedicine System in India, Various Media
Communication parameters In Telemedicine System such as Client- Server type, Peer to peer network,
and Telemedicine through world wide network. We have also discussed about the various Advantages
and Disadvantages of the Telemedicine System and also about the various important application of
Telemedicine.

37
REFERENCES

38
REFERENCES

1. Bashshur RL, Puskin D, Silva J, editors. Telemedicine Journal; Second

Invitational Consensus Conference on Telemedicine and the National Information
Infrastructure; Augusta, Georgia. May 2-4, 1995; 1995. pp. 321–375.[PubMed]

2. Batalden P, Buchanan ED. Industrial Models of Quality Improvement. In:

GoldfieldN, Nash D, editors. Providing Quality Care: The Challenge to Clinicians.
Philadelphia: American College of Physicians;1989.

3. Bayley KB, London MR, Grunkmeier GL, et al. Measuring the Success of
Treatmentin Patient Terms. Medical Care. 1995;33(4, Suppl):AS226–AS235.
[PubMed]

4. Beam CA, Layde PM, Sullivan DC. Variability in the Interpretation of

Screening Mammograms by US Radiologists. Archives of Internal
Medicine.1996;156(2):209–

213. [PubMed]

5. Becich M. Telepathology at the University of Pittsburgh Medical Center.

Telemedicine Today. 1995;3(4):22–23.28.

39
BIBLIOGRAPHY

1. Bashshur RL, Puskin D, Silva J, editors. Telemedicine Journal; Second

Invitational Consensus Conference on Telemedicine and the National Information
Infrastructure; Augusta, Georgia.

2. Batalden P, Buchanan ED. Industrial Models of Quality Improvement. In:

GoldfieldN, Nash D, editors. Providing Quality Care: The Challenge to Clinicians.
Philadelphia: American College of Physicians.

3. Bayley KB, London MR, Grunkmeier GL, et al. Measuring the Success of
Treatmentin Patient Terms. Medical Care.

4. Beam CA, Layde PM, Sullivan DC. Variability in the Interpretation of

Screening Mammograms by US Radiologists. Archives of Internal Medicine.

5. Becich M. Telepathology at the University of Pittsburgh Medical Center.

Telemedicine Today.

WIBLIOGRAPHY

1. https://www.ncbi.nlm.nih.gov/pubmed/29288816
2. https://evisit.com/resources/telehealth-telemedicine-technology/
3. https://www.americantelemed.org/
4. https://chironhealth.com/telemedicine/what-is-telemedicine/
5. https://vsee.com/what-is-telemedicine/

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