DEPARTMENT OF INFORMATION TECHNOLOGY

Vth SEMESTER
OMD553–TELEHEALTH TECHNOLOGY NOTES
Regulation – 2017(Batch: 2019 -2023)
Academic Year 2021 – 22

Prepared by

Dr.G.Sumathy, Assistant Professor/IT

 SYLLABUS
OMD553 TELEHEALTH TECHNOLOGY L T P C 3003

OBJECTIVES:
The student should be made to:
Learn the key principles for telemedicine and health.
Understand telemedical technology.
Know telemedical standards, mobile telemedicine and it applications

UNIT I TELEMEDICINE AND HEALTH 9

History and Evolution of telemedicine, Organs of telemedicine, Global and Indian scenario,
Ethical and legal aspects of Telemedicine - Confidentiality, Social and legal issues, Safety and
regulatory issues, Advances in Telemedicine.
UNIT II TELEMEDICAL TECHNOLOGY 9
Principles of Multimedia - Text, Audio, Video, data, Data communications and networks, PSTN,
POTS, ANT, ISDN, Internet, Air/ wireless communications Communication infrastructure for
telemedicine – LAN and WAN technology. Satellite communication, Mobile communication.
UNIT III TELEMEDICAL STANDARDS 9
Data Security and Standards: Encryption, Cryptography, Mechanisms of encryption, phases of
Encryption. Protocols: TCP/IP, ISO-OSI, Standards to followed DICOM, HL7, H. 320 series
Video Conferencing, Security and confidentiality of medical records, Cyber laws related to
telemedicine
UNIT IV MOBILE TELEMEDICINE 9
Tele radiology: Image Acquisition system Display system, Tele pathology, Medical information
storage and management for telemedicine- patient information, medical history, test reports,
medical images, Hospital information system
UNIT V TELEMEDICAL APPLICATIONS 9
Telemedicine – health education and self care. · Int roduct ion to robotics surgery,
Telesurgery. Telecardiology, Teleoncology, Telemedicine in neurosciences, Business
aspects - Project planning and costing, Usage of telemedicine.
TOTAL : 45 PERIODS
OUTCOMES:
At the end of the course, the student should be able to:
Apply multimedia technologies in telemedicine.
Explain Protocols behind encryption techniques for secure transmission of data.
Apply telehealth in healthcare.

TEXT BOOK:
1. Norris, A.C. “Essentials of Telemedicine and Telecare”, Wiley, 2002.
REFERENCES:
1. Wootton, R., Craig, J., Patterson, V. (Eds.), “Introduction to Telemedicine. Royal
Society of Medicine” Press Ltd, Taylor & Francis 2006
2. O'Carroll, P.W., Yasnoff, W.A., Ward, E., Ripp, L.H., Martin, E.L. (Eds), “Public Health
Informatics and Information Systems”, Springer, 2003.
3. Ferrer-Roca, O., Sosa - Iudicissa, M. (Eds.), Handbook of Telemedicine. IOS Press
(Studies in Health Technology and Informatics, Volume 54, 2002.
4. Simpson, W. Video over IP. A practical guide to technology and applications. Focal Press
Elsevier, 2006.
5. Bemmel, J.H. van, Musen, M.A. (Eds.) Handbook of Medical Informatics. Heidelberg,
Germany: Springer, 1997
1. 6. Mohan Bansal " Medical Informatics", Tata McGraw-Hill, 2004.
 OMD553 –TELEHEALTH TECHNOLOGY
UNIT 1
TELEMEDICINE AND HEALTH
SYLLABUS : History and Evolution of telemedicine, Organs of telemedicine, Global and Indian scenario,
Ethical and legal aspects of Telemedicine - Confidentiality, Social and legal issues, Safety and regulatory
issues, Advances in Telemedicine.

Important Big Questions

 Explain the functional block diagram of telemedicine.
 Explain Ethical and legal aspects of Telemedicine.
 Explain SECURITY in telemedicine systems.
 What is Jurisdictional Issues? Explain the Jurisdictional Issues based on the Licensure, Accreditation and
Clinician Reimbursement.
 Describe the main phase of telemedicine system. Give some examples from the different phase that chart
the progress and advances in telemedicine to the present day.
 Identify the type of telemedicine from the given statement and give the definition of it. a) With real-time
systems, the consultant actively operates a microscope located at a distant site-changing focus,
illumination, magnification, and field of view at will b) T reduce the healthcare costs of chronically ill
patients while providing them access to healthcare providers and maintaining their quality of life. ii. How
is telemedicine categorized based on the technology development? Name them and identify their
features.
 Explain about the Organs of telemedicine
 Write about Global scenario in telemedicine

TELEHEALTH

Telehealth defined:
“The delivery of health-related services and information via telecommunications technologies”
•Could be: (nonclinical services)
•Two healthcare professionals discussing a case over the phone
•Using videoconferencing between providers at facilities in two countries

Telehealth can promote:

•Patient-provider communication
•Patient self-management with provider feedback
•Health literacy Search for diagnosis and educate patients
•Provider-provider consultants

Telemedicine
Definition : Telemedicine
• Telemedicine is the remote delivery of healthcare services, such as health assessments or
consultations, over the telecommunications infrastructure. It allows healthcare providers
to evaluate, diagnose and treat patients using common technology, such
as videoconferencing and smartphones, without the need for an in-person visit.
• These technologies allow communications between patient and medical staff with both
convenience as well as the transmission of medical, imaging and health informatics data
from one site to another.
• It is also used to save lives in critical care and emergency situations.
 • Combination of:
•Telecommunications Technology
•Medicine (clinical services)

Benefits to Healthcare Professionals

 Improved and diagnosis better treatment management
 Continuing education and training
 Quick and timely follow-up of discharged patients
 Access to computerized comprehensive data of
 patients, both offline & real time

Benefits to patients
Access to specialized health care services to under-served rural, semi-urban and remote areas
• Early diagnosis and treatment
• Access to expertise of Medical Specialists
• Reduced physician‘s fees and cost of medicine
• Reduced visits to specialty hospitals
• Reduced travel expenses
• Early detection of disease
• Reduced burden of morbidity
 Where the telemedicine used ?

• Follow-up visits: Virtual follow-ups and check-ups can be used in place of in-person
visits and even help prevent hospital readmissions. The likelihood of missed
appointments and no-shows also decreases with telemedicine — it‘s far easier to log onto
a secure video call than to take time off from work for an in-person appointment.

• Chronic disease management: Telemedicine software and mobile health (mHealth)

software play vital roles in the effective management of chronic diseases. Chronic
diseases already take a toll on patients; telemedicine is an easy and affordable way for
patients to actively maintain control over their health and their relationship with their
caregiver.

• Assisted living visits: Telemedicine offsets the need for in-person visits to assisted
living facilities. Doctors and caregivers can remotely visit their patients at any time of
day, and ultimately reduce unnecessary visits to the hospital.

Classification OR Categories of Telemedicine

Remote patient monitoring (RPM), also referred to as telemonitoring, allows providers to

track and monitor their patients with chronic diseases (diabetes, hypertension, etc.). RPM
solutions equip remote caregivers with vital patient data such as blood sugar or blood pressure
levels so that they can review such data in nearly real time and get notified if a measurement is
abnormal. RPM solutions makes it possible for chronically ill, at-risk or recovery patients to
stay at home instead of being confined to a hospital or clinic.
Examples of RPM :
• Glucose trackers
• Wearable devices that track health and fitness levels
• Smart beds that monitors patients‘ health, communicate with hospital devices and
equipment and automatically make necessary adjustments
• Sensors that monitor the gait and balance of patients with walkers and canes

Store-and-forward/asynchronous applications
• Asynchronous telemedicine solutions, commonly referred to as store-and-forward
telemedicine, enable providers to easily store and share patient medical data with other
providers and practices.
Examples of store-and-forward applications:
• Teleradiology solutions that send patient X-rays to another radiologist
• Teledermatology solutions that send patient photos for remote diagnosis
• Telepsychiatry solutions that enable remote behavioral health treatment

Real-time telehealth applications

• Synchronous telemedicine exists as well. It is also known as real-time telehealth and it
facilitates real-time communication between physician and patient. Generally, real-time
telehealth solutions take the form of audio and video communication and replace in-
person visits.
Examples of real-time telemedicine:
• Live video and audio conferencing
• Emergency virtual consultations
• Remote follow-up visits
Examples for Telehealth vs. Telemedicine

Why Telemedicine/Telehealth?
•Access: Time, Travel, Expense, Information -------- No need for travel.
•Health Provider Collaboration. ------------ prevent patients from becoming advanced cases and
acquiring more cost.
•Enhanced Communications
•TV & Computer Applications common and non- threatening
•Minimize referrals
Communication/Collaboration with specialists
•ER ‗front-line‘ support. →Small hospital will alert a big hospital if it couldn't handle a patient .
so, it consults for or transports this patient.
•Improved professional education
•Saves time, travel to outreach clinics

Challenges of Telehealth
• Infrastructure
• Liability
• Privacy Privacy psychiatry patient will be hesitate of using it.
• End-user lack of knowledge about the benefits, services available in other settings
• Compromised relationship between health professional and patient
• Lack of time to adopt telemedicine
• Equipment costs
• Connectivity costs ,Reimbursement
• A lack of appropriate ,training and educational facilities
• The legal and ethical issues including licencing, privacy and confidentiality
•
 History of Telemedicine
Various forms of telecommunication and information technologies have evolved with time. On
these bases, we can identify four phases of the development of tele-health corresponding to the
use of these technologies (Table-1).

Table – 1: Phases of Tele-health Development

Development phase
Telegraphy and telephony
Radio
Television/space technologies
Digital technologies
Approximate time frame
1840s-1920s
1920 onwards till 1950s
1950s onwards till 1980s
1990s onwards

 Clinical or healthcare information over telephone, or broadcasting it over radio stations..

 Marconi‘s invention of the radio-telegraph in 1897, which was used during the American
CivilWar to send casualty lists and order supplies.

 1906:ECGTransmission
Einthoven, the father of electrocardiography, first investigated on ECG transmission over
telephone lines in 1906.

 1920s: Help for ships

Telemedicine dates back to the 1920s. 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 --- TELEDACTYL

Perhaps it was the cover showed below of "Radio News" magazine from April 1924. The
article even includes a spoof electronic circuit diagram which combined all the gadgets of
the day into this latest marvel! . Hugo Gernsback, predicted that physicians would use not
the telephone, but radio and TV to communicate with patients.

 1955 Telepsychiatry : Closed-circuit television service begun in 1955; used in hospitals

The Nebraska Psychiatric Institute developed a two-way link with Norfolk State Hospital,
112 miles away, in 1964 with further extensions in 1971. This project is one of the first of
many examples of tele-psychiatry.
 1967: Massachusetts General Hospital
This station was established in 1967 to provide occupational health services to airport
employees and to deliver emergency care and medical attention to travelers.
 The National Aeronautics and Space Administration‘s (NASA) efforts in tele-health
began in the early 1960s when humans began flying in space. Physiological parameters
were telemetered from both the spacecraft and the space suits during missions.

 1970s: Satellite telemedicine

Via ATS-6 satellites. In these projects, paramedics in remote Alaskan and Canadian
villages were linked with hospitals in distant towns or cities.

 Project STARPAHC - Space Technology Applied to Rural Papago Advanced Health-

Care. STARPAHC aimed at providing medical care to astronauts in space and to the
Papago Indian Reservation in Arizona. This service was carried out through a van that
was equipped with a variety of medical instruments, including electrocardiograph and x-
ray. The van was linked to the Public Health Service hospital and another hospital with
specialists, by a two-way microwave tele-health and audio transmission.

 In the later parts of 1970s, Alaska Satellite Biomedical Demonstration Program and
various other Canadian projects were begun, to serve far-flung areas.

 The first truly international tele-health program, known as Space Bridge, was
implemented by NASA. It was done to provide relief to people after a terrible earthquake
jolted Armenia in 1988 and cased severe devastation.

 The North-West Tele-health Project set up in Queensland, Australia, was the only major
tele-health project outside North America until 1990. This project was designed to serve
rural communities. The project-goals were to provide healthcare to people in five remote
towns, south of the Gulf of Carpentaria.

 This development was followed by Meaningful Use regulation and the Affordable Care
Act in 2010 where Accountable Care Organizations (ACOs) were created to push for the
maturation of telehealth capabilities.

 It‘s a fairly obvious statement to say that 2016 was the year of telehealth. Even though
the push for its inception started in late 2014 and showed signs of becoming a real
movement in 2015.

 In 2016, $16 million was given by the federal government to improve access to
healthcare in rural areas. Some of the money was designated for the use of the technology
for veterans and others. While we‘re not where many thought we might be, especially
more than 120 years ago, most physicians think the effort is a top priority and will lead to
improved patient outcomes and access to care.

 In 2017, the concept will be unrestricted, paid for and covered, and continue expanding to
a wider audience. For the arguments of telehealth being used to serve the disenfranchised
and the rural poor, telemedicine is set for widespread use.

 There is an expansion of the technology through the use of internet-connected everything

devices and as virtual medical facilities take shape, but there‘s been excitement about the
concept before now. Telehealth is likely a real concept now, but even with new
developments, that doesn‘t mean all of this can‘t be derailed.
 The Evolution of Telehealth

One of the landmark publications of the past couple of decades, Crossing the Quality Chasm,
stated, ―information technology must play a central role in the redesign of the health care system
if a substantial improvement in quality is to be achieved‖. Nowhere is this more true than in rural
communities. New knowledge and new science are being developed all the time. When some
people have access to that new knowledge and expertise and other people do not, disparities
grow. Advances in telecommunication and information technology can help overcome some of
these disparities by redistributing that knowledge and expertise to when and where it is needed.

HOME- AND COMMUNITY-BASED CARE

Health care in the home-based setting has a long history. For example, an 1879 article in the
Lancet talked about using the telephone to reduce unnecessary office visits. In 1925, a cover of
Science and Invention magazine showed a doctor diagnosing a patient by radio, and within
envisioned a device that would allow for the video examination of a patient over distance. Home
monitoring developed more fully in the Mercury space program when the National Aeronautics
and Space Administration (NASA) began performing physiologic monitoring over a distance.
NASA further developed this technology with a pilot with the Papago Indians, the Space
Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project.
The biggest need in home- and community-based care relates to chronic disease. The 100 million
Americans with chronic disease account for about 75 percent of health care expenditures.
Traditionally, chronic disease has been managed through an episodic office-based model rather
than a care management model, which uses frequent patient contact and regular physiologic
measurement. Use of technologies for chronic disease care management has been associated with
reductions in hospitalizations, readmissions, lengths of stay, and costs; improvement in some
physiologic measures; high rates of satisfaction; and better adherence to medication. Studies of
home monitoring programs have shown specific improvements in the management of
hypertension, congestive heart failure, and diabetes.

OFFICE-BASED TELEMEDICINE
Telemedicine has also been used for decades in clinical settings. In 1906, the inventor of the
electrocardiogram published a paper on the telecardiogram. Since the 1920s, the radio has been
used to give medical advice to clinics on ships. Alaska has been a model for the development and
use of telemedicine for decades. For example, community health aides in small villages can
perform otoscopy and audiometry, and the information can be sent to specialists in Anchorage or
Fairbanks to make the determination of whether a patient needs to travel to the specialist for
more definitive treatment. Today, we think of office-based telemedicine as flat-screen, high-
definition units with peripheral devices that can aid in physical examination of the patient. There
are a lot of these units out there, all of which do not talk to each other, and some of which use
proprietary communications methods. If telemedicine is to become as ubiquitous as the
telephone, communications standards will be needed.

Store and forward (S&F), or asynchronous, technologies have been a great advance. For
example, in ophthalmology and optometry, non-mydriatic cameras can be used to perform retinal
screenings in diabetics without needing to dilate the eyes; this has increased screening rates.
Teledentistry has been used to by dental hygienists and dentists to improve access to oral health
care. Dermatology and psychology are two of the biggest areas for telemedicine. Since the
1990s, studies have shown high rates of agreement between diagnoses made in person and
diagnoses made via teledermatology.

ANCILLARY TELEMEDICINE SERVICES

Teleradiology
Teleradiology has been used for at least 60 years. In the past, film was passed through a digitizer;
now most systems use direct digital capture, which allows images to be read overnight in other
countries. Radiologists have promoted the Digital Imaging and Communications in Medicine
(DICOM) standard for transmitting and storing data. By the late 1990s, studies showed that
teleradiology reduced transports for head injuries out of rural areas and that the availability of
teleconsultation with a radiologist significantly affected diagnosis and treatment plans.

Telepathology
Telepathology is less common than teleradiology, but digitization of pathology slides is
becoming much more common. These are very large files, which require the ability to view color
images under different magnifications. A lot of people were concerned about moving these large
files across firewalls, but now a number of models being developed have the image sitting on a
server and the image can be viewed over distance without needing to be moved. Studies have
shown the value of telepathology.

Telepharmacology
Pharmacy has been practiced over distance for a long time. Telepharmacy is facilitated by
computerized physician order entry, remote review, and even remote dispensing. Combining that
with video, being able to review medications, and conducting a video consultation with a patient
allows the whole pharmacy visit to occur over distance. In one recent study on 47 cancer
patients, 27,000 miles of travel were saved because of telepharmacy.
HOSPITAL-BASED TELEMEDICINE
Probably one of the earliest and most famous uses of hospital-based telemedicine was in the late
1950s and early 1960s when a closed-circuit television link was established between the
Nebraska Psychiatric Institute and Norfolk State Hospital for psychiatric consultations. Hospital-
based telemedicine is growing quickly in two areas: stroke care and care in the intensive care
unit (ICU). Evidence shows that with good imaging, high-quality stroke exams can be done over
distance. Although the literature on tele-ICU has been mixed, recent studies indicate associated
reductions in length of stay, mortality, and costs.

A number of devices are being used in inpatient setting as well as in skilled nursing facilities.
Telemedicine reduces avoidable visits to emergency departments for skilled nursing patients.
Some rural skilled nursing facilities exist in communities that do not have physicians, and getting
physicians there urgently can be a challenge.

Organs of telemedicine
Types of Telemedicine
Telemedicine is the use of medical information shared from one site to another using electronic
communications to improve patient‘s clinical health status.
The American Telemedicine Association (ATA) also includes a growing variety of applications
and services using two-way video, email, smartphones, wireless tools, and other forms of
telecommunications technology under the telemedicine umbrella. Patient consultations via video
conferencing, transmission of still images, e-health (including patient portals), remote
monitoring of vital signs, continuing medical education, consumer-focused wireless applications,
and nursing call centers, among other applications, are all considered part of telemedicine and
telehealth.
The Center for Connected Health Policy (CCHP) says, ―Telehealth is not a specific service, but a
collection of means to enhance care and education delivery.‖
According to the CCHP, there are four categories for telehealth use today.
These are:

1. Live video-conferencing Telemedicine Or Real-time telemedicine

Also known as synchronous video, live video-conferencing is a live, two-way interaction
between a person and a healthcare provider using audiovisual telecommunications technology.
This kind of telehealth is often used to treat common illnesses, to determine if a patient should
proceed to an emergency room, or to provide psychotherapy sessions.

Synchronous telemedicine exists as well. It is also known as real-time telehealth and it

facilitates real-time communication between physician and patient. Generally, real-time
telehealth solutions take the form of audio and video communication and replace in-person
visits.
Examples of real-time telemedicine:
• Live video and audio conferencing
• Emergency virtual consultations
• Remote follow-up visits

2. Store-and-forward or asynchronous Telemedicine

Store-and-forward is involves acquiring medical data (like medical images, biosignals etc.) and
then transmitting this data to a doctor or medical specialist at a convenient time for assessment
offline. It does not require the presence of both parties at the same time. Dermatology (cf:
teledermatology), radiology, and pathology are common specialties that are conducive to
asynchronous telemedicine. A properly structured medical record preferably in electronic form
should be a component of this transfer. A key difference between traditional in-person patient
meetings and telemedicine encounters is the omission of an actual physical examination and
history. The ‗store-and-forward‘ process requires the clinician to rely on history report and
audio/video information in lieu of a physical examination.

Asynchronous telemedicine solutions, commonly referred to as store-and-forward telemedicine,

enable providers to easily store and share patient medical data with other providers and practices.

Examples of store-and-forward applications:

• Teleradiology solutions that send patient X-rays to another radiologist
• Teledermatology solutions that send patient photos for remote diagnosis
• Telepsychiatry solutions that enable remote behavioral health treatment

3. Remote patient monitoring (RPM)

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 a great extent in senior living in
order to prevent falls and monitor the vital health statistics of residents.
Examples of RPM :
• Glucose trackers
• Wearable devices that track health and fitness levels
• Smart beds that monitors patients‘ health, communicate with hospital devices and
equipment and automatically make necessary adjustments
• Sensors that monitor the gait and balance of patients with walkers and canes

4. Mobile health or mHealth Telemedicine

mHealth 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. Examples of healthcare apps and how valuable they are for senior care
will be discussed later in this eBook.

Indian Scenario
Initiatives
In a developing country such as India, there is huge inequality in health-care distribution.
Although nearly 75% of Indians live in rural villages, more than 75% of Indian doctors are based
in cities. Most of the 620 million rural Indians lack access to basic healthcare facilities and the
Indian government spends just 0.9% of the country's annual gross domestic product on health,
and little of this spending reaches remote rural areas. The poor infrastructure of rural health-
centers makes it impossible to retain doctors in villages, who feel that they become
professionally isolated and outdated if stationed in remote areas.

In addition, poor Indian villagers spend most of their out-of-pocket health- expenses on travel to
the specialty hospitals in the city and for staying in the city along with their escorts. A recent
study conducted by the Indian Institute of Public Opinion found that 89% of rural Indian patients
have to travel about 8 km to access basic medical treatment, and the rest have to travel even
farther. Telemedicine may turn out to be the cheapest, as well as the fastest, way to bridge the
rural–urban health divide. Taking into account India's huge strides in the field of information and
communication technology, telemedicine could help to bring specialized healthcare to the
remotest corners of the country.

The efficacy of telemedicine has already been shown through the network established by the
Indian Space Research Organization (ISRO), which has connected 22 super specialty hospitals
with 78 rural and remote hospitals across the country, through its geo-stationary satellites. This
network has enabled thousands of patients in remote places, such as Jammu and Kashmir,
Andaman and Nicobar Islands, the Lakshadweep Islands, and tribal areas of the central and
northeastern regions of India, to gain access to consultations with experts in super-specialty
medical institutions.

ISRO has also provided connectivity for mobile telemedicine units in villages, particularly in the
areas of community health and ophthalmology. Other then that, both public and private entities
are aggressively pursuing the use of telemedicine to hasten diagnostics and treatment of a variety
of diseases in India.

 Private hospitals such as Apollo Hospital Group.

 Escorts Heart Institute and Fortis Healthcare.
 The Apollo Hospital Group has networked dozens of remote rural hospitals providing
digital connections to one of its main facilities in. In one example, Apollo has set up a 50-
bed telemedicine center in Aragnoda, a small village in the Andhra Pradesh section of
south India. The facility is equipped with CT-scans, X-ray and ECG equipment as well as
an integrated laboratory and is linked to Apollo's specialized hospitals with connectivity
is conducted through the use of ISDN lines and VSAT. The Indian government has also
made important commitments to telemedicine by reducing import tariffs on infrastructure
equipment
 Department of Information Technology (DIT)
 Indian Space Research Organization
 NEC Telemedicine program for North-Eastern states
 Asia Heart Foundation
 Stategovernments

Hindrances to Telemedicine
 Financial unavailability: There have been several isolated initiatives from various
organizations and hospitals for the implementation of e-medicine projects in India; but
the technology and communication costs, being too high, make it financially unfeasible
 Lack of basic amenities: In India, nearly 40% of the population lives below the poverty
level. Basic amenities like transportation, electricity, telecommunication, safe drinking-
water, primary health-services, etc., are missing. Any technological advancement can‘t
change a bit when a person ―has nothing‖ to change.
 Literacy rate and diversity in languages: Only 65.38 % of India‘s population is literate,
with only 2% well-versed in English. So the rest of the people are facing a problem in
adopting telemedicine. Also, the presence of a large number of regional languages makes
the applicability of a single software difficult for the entire country.

Advantages of Telemedicine in India

 Doctors licensed to practice all over India
 Maximum utilization of limited resources
 Saves travel, time and money
 Make geographical history
 Motivation for computer literacy among doctors
 Useful in designing credits for re-certification of doctors
A time is approaching when telemedicine/e-health initially shall be visibly
practiced in the majority of Indian hospitals, as a separate department, before eventually fusing
into the respective medical specialties.

Global scenario
Telemedicine can also be concisely referred to as ―the use of information and telecommunication
technologies (ICT) in medicine‖ . Telemedicine is just not only for remote monitoring or
diagnosing a patient (comparative performance of seven long-running telemedicine networks
delivering humanitarian services .It also includes e-learning techniques (to remotely deliver
education both to health care workers and to patients), and teleconsultation (aka telecounseling
or expert second opinion) services. This latter refers to any consultation between doctors or
between doctors and patients on a network or video link (e.g., Facetime, intranet, Internet,
Skype, etc.), as opposed to the ―in person‖ counseling where no ICT is needed to manage the
interaction between the patient and the physician(s).

In developed countries several programs have been deployed, and they have been promptly
reported for 10–15 years , where the program has been mainly used for remote education (76%
of the considered cases), without neglecting other goals such as wound cases (55%), and
psychiatry cases (54%), and store-and-forward ECG (ElectroCardioGraphy) recordings.

To provide the reader with an economic evaluation of the effort, the telemedicine market in
Europe increased from an amount of €4.7 billion in 2007 to the amount of €11.2 billion in 2012 –
the European Commission (EU) estimates . Additional world-wide estimations assert that the
global telehome and telemedicine market reached an amount of US$ 13.8 billion 2012, US$ 16.3
billion 2013, US$ 19.2 billion 2014, and this market is expected to grow up to US$ 35.1 billion
in 2018, US$ 43.4 billion in 2019, with a compound annual growth (CAGR) of 17.7%. Some
more estimations evaluate that the European telemedicine market grew from US$ 3.1 billion in
2010 to US$ 4.8 billion in 2011, and will almost triple to US$ 12.6 billion in 2019 at a CAGR of
12.82%; at the worldwide level, the market of telemedicine reached an amount of US$ 14.4
billion in 2015, and is expected to grow up to US$ 34.0 billion in 2020, with CAGR of 18.6%.

Much less effort has been spent for similar initiatives in developing countries. Probably, this is
due both to the much smaller return of investment (ROI), to a limited budget available, and to the
greater difficulties expected or encountered also due to the lack of technological infrastructures.
Moreover, while telemedicine programs in developed countries in most cases may easily deploy
an emergency strategy, such as sending out an helicopter to rescue the patient and to transfer
him/her to the nearest hospital in a very short time, similar situations in developing countries are
generally more expensive and much harder to be deployed. Finally, in developed countries,
telemedicine is side-by-side to more conventional health care, completing it, while in developing
countries telemedicine in most cases is an alternative, or even the only alternative, to
conventional health care. Nevertheless, telemedicine applications in developing countries could
be a leverage to provide wide populations with basic health care services and to close the
distance between rural areas and specialized hospitals usually located in big cities.

Efficacy and the cost-effectiveness of telemedicine compared with conventional health care still
are to be properly evaluated in fact, major aspects to be considered include the amount of saved
lives (e.g., some people would have died without the aid of a telemedicine system), and the
quality of life of saved people (e.g., some people would have been completely restored if the
telemedicine system could suggest them a first-aid assistance). As for the cost-effectiveness, to
the best of our knowledge, are the only ones to measure the economic benefits achieved by a
telemedicine program: they just sum up the travel costs to move a specialist physician from a
main hospital to the remote hospital, or to move the patients from the remote hospitals to the
main hospital.

According to the previous considerations, telemedicine applications in developing countries need

to be studied, designed, and evaluated according to specific criteria, which have to take into
account cultural, environmental, organizational, and economic peculiarities of the considered
countries and populations.
 Telemedicine services
To obtain an impression of the current state of telemedicine service provision, four of the most
popular and established areas of telemedicine were surveyed specifically. Respondents were
asked to indicate whether or not their country offered a service in each field, and if so, to give its
level of development. Levels of development were classified as ‗established‘ (continuous service
supported through funds from government or other sources), ‗pilot‘ (testing and evaluation of
the service in a given situation), or ‗informal‘ (services not part of an organized programme).

The survey examined four fields of telemedicine:

TELEMEDICINE RESULTS
 Teleradiology – use of ICT to transmit digital radiological images (e.g. X-ray images)
from one location to another for the purpose of interpretation and/or consultation.
 Telepathology – use of ICT to transmit digitized pathological results (e.g. microscopic
images of cells) for the purpose of interpretation and/or consultation.
 Teledermatology – use of ICT to transmit medical information concerning skin
conditions (e.g. tumours of the skin) for the purpose of interpretation and/or consultation.
 Telepsychiatry – use of ICT for psychiatric evaluations and/or consultation via video
And telephony.

Advances in Telemedicine
Recent Advances
 The first randomised controlled trial of home telenursing showed evidence of its cost
effectiveness
 Electronic referrals are a cheaper and more efficient way to handle outpatients
 General practitioner teleconsulting may be cheaper than traditional consulting in some
circumstances
 Decision support over video links for nurse practitioners dealing with minor injuries is
shown to be effective and safe
 Call centres and online health meet a demand from the public, but are unlikely to be
cheaper for the NHS.

Recent technological advancements have changed the way we see the world, paving the way for
the growth of concepts such as telemedicine in the field of medical technology. Telemedicine is a
method of providing clinical healthcare to someone from a distance by the use of
telecommunication and information technology.

Previously, telemedicine was reserved for treating patients located in remote areas, far away
from healthcare facilities, or in locations with a shortage of medical professionals. However, in
today‘s interconnected world, I believe telemedicine is now a tool for convenient medical care—
its use is no longer limited to overcoming distance barriers or improving access to medical care.
Today‘s connected patient wants to waste less time in the waiting room at the doctor‘s surgery
and get immediate care for minor but urgent conditions when they need it.

Importance of TeleMedicine

Benefits for Patients:

1. No travel expenses and no time spent waiting around for appointments
2. Less interference with childcare or eldercare responsibilities
3. Reduced medical costs provide value to the patient
4. Extended access to consultations with specialist doctors
Benefits for Providers:
1. Increased revenue
2. Fewer missed appointments and cancellations
 3. The ability to treat more patients over time
4. Better patient follow-up and improved health outcomes

Trends in Telemedicine
1. Patient Data Collection and Data Analytics: During a telemedicine session, patient
information is automatically captured by the use of telemedicine services, such as sensors
and mobile apps. Using this data and the slew of modern devices available, patient self-
monitoring has been huge in 2017 and will continue to grow in 2018 and beyond. Some
devices track patient ECG‘s and send the results to doctors, providing an invaluable tool
for healthcare professionals to monitor cardiovascular activity. Also, Big Data analytics
plays a key role in analyzing data from many patients, helping to improve telemedicine
treatments as a whole going forward. Patient data collection can help identify risk factors
for certain illnesses, assisting physicians with recommending prophylactic treatments.

2. Mobility and Cloud Access: By 2018, it‘s estimated that 65 percent of interactions with
healthcare facilities will occur with mobile devices. 80 percent of doctors already use
smartphones and medical apps in their practice. Hospitals and insurance companies now
store medical records in the cloud so that patients can access their test results online 24/7.
This, in turn, decreases paper usage and saves time. Cloud data warehouses are one way
of storing the data securely and efficiently.

3. Enhanced Security: With lots of data being collected from patients to assist with
telemedicine services, data security is vital. There are different techniques available today
which help to enhance data security in telemedicine, including:
 Conducting a HIPAA security check once a year to reduce data security risk
factors
 Insisting on encryption of data on all portable devices
 Conducting more frequent penetration testing and vulnerability assessments of IT
systems

4. Better Investment Opportunities: Because telemedicine is one of the fastest growing

segments in the healthcare industry, many organizations are investing in it. Mergers
between small and larger telemedicine operators provide financial stability to smaller
companies and a platform to provide telemedicine care effectively. Also, larger
telemedicine providers are collaborating with international medical institutions, helping
them to spread their expertise abroad, widening the telemedicine market, and generating
more revenue. Investment opportunities in telemedicine will only increase as India and
China open their doors to telemedicine practices from the west.

5. Better Healthcare Apps: In the coming years, we can expect more personalized
telemedicine apps for both patients and clinicians, with the flexibility to specify the
information transmitted between doctor and patient. Telemedicine app development also
will give rise to mHealth, also known as mobile Health. Apps such as MDLIVE, Amwell,
MyTeleMed, and Express Care Virtual will facilitate convenient interactions between
patient and physician.

Telemedicine services provide cost-effective treatments and less wasted time for patients and
physicians. Increased prevalence of chronic diseases, technological advancements -- particularly
in software -- and a rise in the aging population are major factors driving the massive growth in
telemedicine. Expect to see telemedicine become much more prominent in healthcare over the
coming years, with more patients than ever having access to top-quality medical care at their
fingertips
 ETHICAL ISSUES

• TeleHealth, telemedicine, and eHealth have vastly improved the ability to electronically
record, store, transfer and share medical data.
• The challenge for the wide spread use of telemedicine lies in identifying emerging
concerns and develop policies and environment so that privacy, security and
confidentiality of the information is ensured.

Confidentiality
• In telemedicine interaction takes place between doctors and patients over large
distances, involving the use of computers, telephones, fibre optic cable and other means
of data transmission and therefore, the issue of confidentiality is genuine and requires to
be addressed.
• It has often been felt that the medical institutes are not adequately equipped to handle
electronic confidentiality issues.
• (i) Unintentional disclosure can happen when the information is displayed on a computer
screen without the presence of any person working there.
• (ii) ―Routine‖ information is circulated without the knowledge of the patient, even though
this may be based on some kind of consent by him.
• (iii) Providing information to third parties, such as insurance company or with an
employer, without the consent of the patient also results in compromising data privacy.
• Some of these measures include protection through password, restrictions on the
operator to particular records, data encryption, and digital signatures.
• medical ethics rules provide for protecting and maintaining confidentiality of patient
records.
• Hippocratic Oath and the Medical Association’s Code on Medical Ethics signifies this
obligation on the part of medical practitioners. Under these circumstances, physicians are
expected to maintain a high level of confidentiality standard.
• Telemedicine guidelines must ensure that information regarding a person‘s physical
condition, psychological condition, healthcare and treatment shall not be released without
the patient‘s consent.
• American Medical Association (AMA) guidelines for confidentiality on AMA websites.
• HIPAA is the 1996 federal Health Insurance Portability and Accountability Act in
USA. The main objective of the law is to make it easier for people to maintain health
insurance, protect the confidentiality and security of healthcare information data and
help the healthcare industry control administrative costs.
• The aim of this act is to protect personal patient data in all forms. Under this act, any
healthcare provider must obtain consent to use or disclose protected health information in
compliance with a consent to carry out treatment, payment or healthcare operations

Professional Standards
• Telemedicine to be an effective tool for healthcare and to be ethically acceptable will
require addressing issues such as:
1. erosion of the patient-doctor relationship
2. threats to patient privacy,
3. forcing one-size-fits-all implementations,
4. and the temptation to assume that new technology must be effective.
• Physicians are expected to comply with nationally recognised health online service
standards, if any, and general code of medical ethics.
• A physician‘s professional approach relating to the diagnoses, scope of care, or treatment
should not be limited or influenced by non-clinical considerations of telemedicine
technologies.
 Ethics and Legality of Internet Based Medical Services:

• To date, the use of the Internet to deliver medical services has been largely restricted to
advice in a patient-carer setting or to the dispensing of prescriptions. In the former
situation, the value of the online therapy to the patient is clearly dependent on the
credentials and expertise of the carer. Even if the qualifications and status of the clinician
are above question, (and these may be difficult to assess) it does not follow that this
person can exploit the new medium to offer the care that he or she would provide in a
traditional consultation. There are also many opportunities for misunderstanding, due to
the absence of visual clues and the tendency for the mind to fill in knowledge gaps in an
idealistic way.

SECURITY IN TELEMEDICINE SYSTEMS

• Online privacy and security issues of the Internet are subjects under constant discussion.
Data capture stage
• Wrongly identified participants in the telemedicine process (Doctors, Patient,Others)
• Lack of control to data access
Communication stage
• Cross talk on point-to-point links (such as dedicated link, dial-up, direct connection)
• Involvement of intermediaries (such as Internet browsers, video bridges),
• Problems in data management in store-and-forward mode of telemedicine
Data review and storage stage
• • Long-term electronic and physical files (disc, tape, paper)
• • Incidental information, (cache memory, printouts)

The following are typical security risks when working with Internet
• Hacking: The exploiters sometimes attempt to hack Internet related information with just
malicious intents arising out of curiosity, whereas others may do so with criminal
inklings of stealing or altering data.
• Malware: Malware, is a piece of software developed with the specific intention of
attacking
a computer. These include software like viruses, worms, and Trojans. Malware is also
known as Malicious code.
• Phisher: Phishing is an attempt to play fraud on email to gain unauthorised access to
secured information contained therein. This is done to target a specific group of people
or an organisation.
• Spam: Spam is an unsolicited advertising materials that are put on the Internet. They
generally result in wasting network resources such as bandwidth and storage space in
mailbox with junk.
• Security assessment in a telemedicine set up involves evaluation of as to who has been
authorized for access to the system. This should include all elements of the system such
as computer terminals, servers, communications equipment, videoconferencing, and
network switching devices.
 • In a secure telemedicine system, it is necessary to establish the identity of the user by
employing an authentication mechanism. The telemedicine system must then determine
the rights of the user provided in the user profile. Based on this information, the user has
to work with data under defined roles, e.g., create, add, view data, etc. based on the
identity of the user and the roles the user in the process.
• Telemedicine systems must implement appropriate security policies which should
clearly define measures for access control, audit trails, physical protection, maintaining
the confidentiality and integrity of data

The components affecting the secure healthcare systems,

• Confidentiality: Confidentiality implies that the information is not made available to

who are not authorised.
• Authentication: Authentication involves all parties in the telemedicine process to
provide a means of proving their identity before they can get access to the system. The
medical professional is validated before allowing access to patient data by using
passwords, tokens, digital certificates or biometrics
• Integrity: Integrity in a telemedicine system relates to the accuracy of the transmitted
and received data. This assures the detection of any difference in the contents of a
transaction.
• Non-repudiation: It requires that a party to a transaction may not claim later that they
did not participate in that particular transaction.
Availability: This ensures that the system continues to perform its intended function without
getting disrupted by various technical reasons, which could be latency in mobile data service or
quality of service problems

Telemedicine application system must include the following security measures built in the
system (Bedi, 2003):
• (i) List of persons including doctors, paramedical staff and others who are authorised to
have access to patient‘s health related information.
• (ii) Type of security technology used such as password, fingerprint and smart card.
• (iii) Type of encryption used for storing medical and associated data.
• (iv) Type of encryption used for transmitting medical information over networks.

The security and privacy of data can be ensured by the following measures:
• (i) Physical security measures: These include access controls, private networks,
firewalls, authentication, encryption, time-stamping
• (ii) Specific measures: For securing email and web servers
Access Controls
• User password is considered to be an effective method to control access to a system,
which can be potentially an easy target of attack. The user ID (identification) often becomes
common knowledge, as most of the times, the account name is the user‘s email address.
Firewalls
• The function of firewall is to prevent unauthorised users getting access to a private
networks,
which are connected to the Internet. If you wish to implement telemedicine, you will
certainly need to secure your data from being accessed by those for whom it is not meant.
• All messages entering or leaving the system pass through the firewall, which examines
each message and blocks those that do not meet the specified security criteria
• A network-based application layer firewall is also known as a proxy-based firewall or
proxy gateway. Because it acts on the application layer, it inspects the contents of traffic,
blocking specified content, such as certain websites, viruses, or attempts to exploit known
logical flaws in client software.

• Encryption
Encryption of electronic medical information is an advisable method to protect a patient‘s
privacy just as a locked file cabinet. Communications networks are shared by a community
of people. In contrast, hospitals do not archive medical records in public library. Access
is given only to such medical staff authorised
• Cryptography is the art of protecting information by encrypting it.
• cryptographic keys are classified as:
(i) Public key cryptography
(ii) Private key cryptography
• Data Encryption Standards (DES) as defined in the IT Acts of respective countries
also apply to telemedicine applications. Public and private keys can be used to facilitate
the mechanism.

Authentication
• Authentication is the process of identifying an individual, usually by a username and
password or with any of the modern methods like biometrics.
Once the user is authenticated, the user is authorised to use various resources like browsing, file
transfer, order, etc. Biometrics is based on measurable physical characteristics like computer
analysis of fingerprints or speech that can be automatically checked

Digital Certificate
• Digital signature, basically, is an attachment to an electronic message to verify that a user
sending a message is who, he or she claims to be and to provide the receiver with the
means to encode a reply (Saroha, et al., 2013).
• The most widely used standard for this is an ITU standard called X.590.
• The digital certificates are issued to individuals who wish to send encrypted messages for
which they need to apply to a Certificate Authority (CA) in their particular country.
• The CA issues an encrypted digital certificate containing the applicant‘s public key along
with other identification information (Beal, 2016). The certificate includes information about
the key, information about its owner‘s identity, and the digital signature of an entity that
has verified the certificate‘s contents are correct.

Digital Timestamp
• The process of securely keeping track of the creation and modification time of a
document is termed as time-stamping. Whenever a document is created, sent or received,
it will create a timestamp on the document.
• The result is simple, secure, independent and portable proof of electronic record
integrity.
• Timestamping is an important method for the long-term preservation of digital signatures,
time recording of data objects, maintaining records for protecting copyright and
intellectual property and other legal services.

SECURING APPLICATIONS: EMAIL AND WEB SERVERS

SECURING APPLICATIONS: EMAIL AND WEB SERVERS

• There are programs which provide a user verification process to establish the origin of the
message as well as address along with other requirements of confidentiality and message
integrity.
• coordination is required in the application of the encryption, authentication techniques
applied in different applications to ensure that everyone involved in the system uses the
same approach.
• Telemedicine environment is a kind of distributed system in which the information
processing is distributed over several computers rather than confined to a single machine.
• There are a number of tools available to ensure security of such distributed information
systems.
Secure Sockets Layer (SSL)
• The Secure Sockets Layer (SSL) is a computer networking protocol that manages server
authentication, client authentication and encrypted communication between servers and
clients.
• ―sockets‖ refers to the sockets method of transporting data back and forth between a
client and a server program in a network, or between program layers in the same
computer
• It appears to be a good choice to solve authentication and privacy problems between two
sites using TCP
• SSL is not suitable for ―store-and-forward‖ environments (as mail) because once the data
is read off, the proof of its origin is lost.
Transport Layer Security (TLS)
• Transport layer security is a cryptographic protocol that ensures privacy between
communicating applications and their users on the Internet.
 • The combination of SSL/TLS is the most widely employed security protocol used today.
It is generally found in applications such as web browsers, email and basically any
situation where data is required to be securely exchanged over a network.
• The examples include file transfers, VPN connections, instant messaging and voice over
IP
• TLS is a more secure and efficient protocol than SSL. The key differences between the
two are message authentication and, supporting newer and more secure algorithms.

LEGAL ISSUES
• Doctor-patient relationship
• Jurisdiction
• Licensure
• professional accountability
• Informed Consent
• Continuity of Care
• Medical Records
• Prescribing

Doctor-Patient Relationship
• A question comes up that if a local doctor or paramedic treats a patient through a
telemedicine service, and in that process, sends an x-rays for interpretation and evaluation
report to a specialist, who should be held responsible towards the patient? Would it be the
local doctor or the specialist who is sitting hundreds of kilometres away?
• (i) Personal meeting between the doctor and patient
• (ii) Examination of the patient by the doctor
• (iii) Review of the patient‘s records by the doctor
• (iv) Payment to the doctor for services by the patient.

• The relationship gets clearly established when the physician agrees to undertake
diagnosis and treatment of the patient, and the patient agrees to be treated.
• If the doctor does not contact or examines the patient directly, and only speaks with the
doctor, no relationship is established.
• case of referring a patient to a specialist by the doctor, the specialist completely takes
over the case for further treatment.
• In telemedicine, however, the scenario is different as the referring doctor is not
bound to follow the advice of the specialist provided over the telemedicine network.
• even minimal or indirect contacts between doctors and patients via telemedicine may be
a sufficient ground for malpractice liability.

Jurisdiction
• Telemedical practice involves the applicable jurisdiction in which a lawsuit could be
filed.
• problem lies in choosing between the state in which the physician is licensed or located
versus the patient‘s state of residence.
• They must possess appropriate licenses for all jurisdictions where patients receive
care.
• a doctor practicing telemedicine may need to be aware of laws and regulations in
other states that may have jurisdiction over his activities, particularly in the area of
physician licensing.
• A more complex situation arises when telemedicine is practiced internationally.
• can one country has the authority to impose its laws on a foreign telemedicine
provider.
 • it urgently requires dialogue and discussion amongst various stake holders to regulate the
practice of telemedical services at international level.

Licensing
• physician-to-physician communications have not been subject to licensing
requirements (Chen, 2006), their communications can take a variety of forms including
the transmission of x-rays, clinical histories and pathological and laboratory data for
evaluation and interpretation for a specific consultation required from a physician with
special expertise.
• When a telemedicine consultation crosses state boundaries, the provider have to be
licensed in one state, the other, or both.
• If a physician would like to practice in more than one state, it would be necessary to
obtain a license in each state.
• a national licensing system would be better as it would help eliminate state-to-state
licensing issues. Under this arrangement, doctors can treat patients in any state as long as
they are licensed in at least one state in the country.

Informed Consent
• Another issue in telemedicine practice involves the doctrine of informed consent, which
requires physicians to disclose to their patients’ available treatment choices along
with the risks and benefits of each.
• to establish true informed consent, a physician is required to disclose all risks that
might affect a patient’s treatment decisions. Based on the same lines, it requires a
doctor to inform the patient the experimental nature of telemedical procedures.
• The question arises as to whether the attending doctor should obtain consent of the
patient to solicit telemedical.
• Consultation which of these doctors bears the main responsibility to inform the
patient of any treatment alternatives or risks involved in those.

Continuity of Care
• To ensure continuity of care, the patient should be able to get follow-up care or
information from the physician who initially used telemedicine technology to treat the
patient.
• Proper documentation must be maintained by physicians
• Such documentation must also be made available to the patient and to any identified
care provider of the patient immediately after the encounter, subject to the patient‘s
consent

Medical Records
• The patient medical record should include records of past care, prescriptions,
laboratory and test results, evaluations and consultations, copies of all patient-
related electronic communications, including patient-physician communication.
• The patient record created during the use of telemedicine technology must be properly
documented and made accessible to both the physician and the patient.

Prescribing
• medication formulations should be limited to ones that are deemed safe while using
telemedicine.
• It would be desirable that detailed documentation is created and stored independently
regarding clinical evaluation and resulting prescription.
 Advances in Telemedicine
• The first randomized controlled trial of home telenursing showed evidence of its cost
effectiveness
• Electronic referrals are a cheaper and more efficient way to handle outpatients
• General practitioner teleconsulting may be cheaper than traditional consulting in
some circumstances
• Decision support over video links for nurse practitioners dealing with minor injuries
is shown to be effective and safe
• Call centres and online health meet a demand from the public.
• today‘s interconnected world, I believe telemedicine is now a tool for convenient medical
care—its use is no longer limited to overcoming distance barriers or improving access
to medical care.
• Today‘s connected patient wants to waste less time in the waiting room at the doctor‘s
surgery
• get immediate care for minor but urgent conditions when they need it.

Other Issues and Challenges

Improving User-Acceptance of Health-Care Telemedicines:
Tele-health represents a new approach to health-care, with the potential for improving
accessibility and reducing costs. Over the years, technology has become increasingly interactive,
cheaper and standardized. Despite this, the uptake of technology has been low. One of the main
reasons is that the introduction of telemedicine in health-care requires more than technology and
software----organizational and cultural change is required, as well. A suggested approach is
based on the principals of service-quality and high-quality management, to produce a partnership
between the users and developers of new technologies. This will, in turn, make it possible to
bring user-validated requirements into the design of the system and create feelings of ownership
and motivation on the part of users, in order to prepare their environment for the change. This
methodology has been effectively used in various projects of the telemedicine Application
Program of the European Commission.

Managing the 'Fit' of Information and Communications Technology in Community-

Healthcare.
The 'fit' of information and communication technologies (ICT) in community health is important
in meeting the needs of patients, carers, staff and organizations in the delivery of services. A
good fit leads to greater efficiencies and effectiveness in use of ICT. There is a need to look not
only at the role of ICT, but also at how to manage ICT and make a good ICT fit so as to enhance
community health-services. Tele-health was identified as the application of ICT to enhance
population-health, health promotion and delivery of health-service. A participatory process is
critical to determining needs and potential uses, as well as to the successful design and
implementation of ICT in health. There would be an additional value in ensuring a diversity of
desired outcomes, which can balance costs and benefits while fostering capacity and technical
sustainability.

Preparing Doctors & Surgeons for the 21st Century - Implications of Advanced Technologies
An entire spectrum of advanced technologies and concepts has been presented, from the new
clinical applications to highly speculative possibilities. Not all of these technologies will survive
the long process to clinical usefulness, but those that do may well revolutionize surgery and other
medical procedures. With such change comes the ethical and moral responsibility to consider
them not only in the light of improvement of patient care, but also in their impact on society as a
whole. Fundamental changes in the organization, financing, and delivery of health-care have
added new stress-factors or opportunities to the medical profession. These new potential stress-
factors are in addition to previously recognized external and internal ones. The rapid deployment
of new information-technologies will also change the role of the physician towards being more
of an advisor and provider of information. Many of the minor health-problems will increasingly
be managed by patients themselves and by non-physician professionals and practitioners of
complementary medicine.

Library Outreach:
Addressing the "Digital Divide": A "Digital Divide" in information and technological literacy
exists today between small hospitals and clinics, in rural areas, and the larger health-care
institutions in the major urban areas of the world. Some efforts have been made to address
solutions to this disparity; one of them is the outreach-program of the Spencer S. Eccles Health-
Sciences Library at the University of Utah, in partnership with the National Network of Libraries
of Medicine-- Midcontinental Region, the Utah Department of Health, and the Utah Area Health-
Education Centers. In a circuit-rider approach, an outreach librarian offers classes and
demonstrations throughout the state that teach skills of information-access to health-
professionals. Provision of traditional library-services to unaffiliated health-professionals is
integrated into the library's daily workload, as a component of the outreach program.

Managing Changes in Informatics-The Organizational Perspective:

The successful introduction of information-systems into any healthcare organization whether a
primary care physician's office, or a complex health care organization-requires an effective blend
of good technical and good organizational skills. A system that is technically excellent may
prove woefully inadequate if people resist its implementation. The person who knows how to
manage the organizational impacts and stresses of new information-systems can significantly
reduce behavioral resistance to change and resistance to new technology in particular to achieve
a more rapid and productive introduction of those systems.

Patient e-Care – Addressing the Concerns of the Providers

Online patient-care or patient "e-care" could revolutionize the centuries-old paradigm of medical
practice. Patient e-care can bring back the "house call" experience, long missed by consumers,
and could potentially allow healthcare to become proactive rather than reactive. Moreover,
patient-monitoring and interactive management data can be fed directly into patient‘s electronic
medical records. Consumers/patients embrace the concept of e-care. Providers, however, tend to
be threatened by a change of the medical practice paradigm and by the (perceived) impingement
upon providers' hectic time-schedules. Most providers felt that they did not have enough time in
their busy schedules (i) to learn the new technology required, (ii) review daily patient-data, or
(iii) interact with their patients online.

Providers expressed a need for solutions that offer better patient-care but would also not require
more time from the providers. Technical e-care solutions must address both patient-wants and
provider-concerns. Solutions that save time for providers, while still offering the advantages of
patient ecare, must be found. For example, Internet software that automatically monitors and
even manages some aspects of a patient's condition, while keeping the provider informed,
appears to be one solution.

e-Content: the Challenge of Providing Authentic & Quality Health- Information:

Health information is amongst the most frequently accessed informations on the web.
Accordingly, the breadth of health-information offered on the web is vast. However, a new
public-health concern is the extremely variable quality of health-related information on the
Internet, ranging all the way from reliable, evidence-based information, to fraudulent,
commercially motivated, unbalanced or misleading information. For patients and consumers, and
even for health-professionals, it is often difficult to judge the trustworthiness of digital
information.
 INDIRECT QUESTIONS AND ANSWERS

Answer∷
i) The benefits of Telemedicine
 Many patients feel uncomfortable to go to hospital or doctor-chamber. This system creates communication among patients &
healthcare professionals maintaining convenience & commitment. Moreover, through Telemedicine medical information and
images are kept confidential and safely transferred from one place to another. So, people can believe this system and feel
comfort to seek help from it.
 It saves lives in the emergency situations, while there is no time to take the patient at a hospital.
 In many rural communities or remote places or post-disaster situations, consistent healthcare is unavailable. Telemedicine can
be applied in such places or situations to provide emergency healthcare.
 This system is useful for the patients residing in inaccessible areas or isolated regions. Patients can receive clinical healthcare
from their home without arduous travel to the hospital.
 Modern innovations of information technology such as, mobile collaboration has enabled easy information sharing and
discussion about critical medical cases among healthcare professionals from multiple locations.
 Telemedicine has facilitated patient monitoring through computer or tablet or phone technology that has reduced outpatient
visits. Now doctors can verify prescription or supervise drug oversight. Furthermore, the home-bound patients can seek
medical-help without moving to clinic through ambulance. Thus, cost of health care has been reduced.
 This system also facilitates health education, as the primary level healthcare professionals can observe the working procedure
of healthcare-experts in their respective fields and the experts can supervise the works of the novice.
 Telemedicine eliminates the possibility of transmitting infectious diseases between patients and healthcare professionals.

ii) The technology issues faced during communication through telemedicine consultation

Here are seven telemedicine concerns to take into account and effective strategies for overcoming them.

1. Reimbursement

Getting reimbursed for telemedicine services can prove problematic for physicians and other
healthcare providers. Medicare, for example, offers telemedicine reimbursement coverage, but with limitations.
Reimbursement is possible for services covered under the Medicare Chronic Management Program, such as
services for patients who have at least two or more chronic health conditions. These conditions must persist at least
one or more years or until death to be considered for reimbursement claims.

2. Lack of Integration

If your Electronic Health Records (EHR) system doesn't coordinate with the platform you're using to provide
telemedicine services, you likely will complicate your workflow records.

By using a platform that integrates with your EHR, you can record your established workflow and ensure your
patients’ e-visits are properly documented and updated for future visits.

3. Lack of Sufficient Data for Care Continuity

A lack of platform integration can also interrupt continuity of care. If a patient receives telemedicine from one service
provider, but chooses another provider for his next e-visit, then the second physician may not have all the information
she needs to diagnose the patient’s problem. The best solution is to inquire where your patient previously received
telemedicine services, including those created at hospitals and providers with other medical facilities.

4. Service Awareness

If your patients aren't aware of your telemedicine services, then the service won't get used. With approximately 96
percent of large employers planning to offer telemedicine services to their employees, it's a missed opportunity if your
patients aren't aware that you're offering these services.

5. Patients’ Lack of Technical Skills

When patients don't understand how to use telemedicine services, it can reduce utilization and hamper
accessibility. It’s a good idea to survey patients before launching your telemedicine services, and asking
which devices they would be most comfortable using when accessing your telemedicine services.

6. Expensive Technology

When you add up the cost of equipment and the cost of services to provide care, telemedicine expenses can be a
concern to physicians, hospitals and medical practices. You may be able to reduce expenses by opting for bundled
services or those that offer a flat fee, while keeping in mind that as the use of telemedicine continues
to grow, technology expenses and service costs will continue to go down.

7. Privacy Concerns

Telemedicine services can be convenient, but they can also provide a gateway to security and privacy issues, while
accessing patient data over the Internet.

HIPAA’s privacy and security rules require that the information gathered through a telemedicine service is encrypted,
and you’re network connections. Additionally, when contacting patients, you have to be sure you are messaging them
across a secure connection. Before you record and store video calls, you need to get the permission of your patients.

iii) Specify the critical success factors for sustaining telemedicine network

The Critical Success Factors (CSF) can be defined as a limited number of characteristics, conditions or variables
that has a direct impact on viability, efficiency and effectiveness of a project,
program or an organisation. Based on the findings of this research it is noted that CSF for implementing
telemedicine are:
a) Supporting Government Regulations and Policies
b) Adopting standardised Project Management practices
c) Acceptability of public
d) Political Support
e) Availability of Technological Infrastructure including hardware, software and adequate bandwidth
f) Availability of sustainable funds
g) Clearly defined legislation
h) Clearly defined telemedicine referral mechanisms and protocols
i) Adequate trained human resources
j) Communication and linkage between stakeholders.
2. Describe the main phase of telemedicine system. Give some examples from the different phase that chart the
progress and advances in telemedicine to the present day.

Answer: The main phase of telemedicine system : 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.
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.
The different phase that chart the progress

Benefits for patients

Some other benefits of telemedicine include:
 Lower costs: Some research suggests that people who use telemedicine spend less time in the hospital,
providing cost savings. Also, less commuting time may mean fewer secondary expenses, such as childcare
and gas.
 Improved access to careTrusted Source: Telemedicine makes it easier for people with disabilities to
access care. It can also improve access for other populations, including older adults, people who are
geographically isolated, and those who are incarcerated.
 Preventive care: Telemedicine may make it easier for people to access preventive care that improves their
long-term health.
 Convenience: Telemedicine allows people to access care in the comfort and privacy of their own home.
This may mean that a person does not have to take time off of work or arrange childcare.
 Slowing the spread of infection: Going to the doctor‘s office means being around people who may be
sick, often in close quarters.
Benefits for healthcare providers
Healthcare providers who offer telemedicine services may gain several benefits, including:
 Reduced overhead expenses: Providers who offer telemedicine services may incur fewer overhead costs.
For example, they may pay less for front desk support or be able to invest in an office space with fewer
exam rooms.
 Additional revenue stream: Clinicians may find that telemedicine supplements their income because it
allows them to provide care to more patients.
 Less exposure to illness and infections: When providers see patients remotely, they do not have to worry
about exposure to any pathogens the patient may carry.
 Patient satisfaction: When a patient does not have to travel to the office or wait for care, they may be
happier with their provider.

3) A) Identify the type of telemedicine from the given statement and give the definition of it.
a) With real-time systems, the consultant actively operates a microscope located at a distant site-
changing focus, illumination, magnification, and field of view at will.
b) T reduce the healthcare costs of chronically ill patients while providing them access to healthcare
providers and maintaining their quality of life.

ii. How is telemedicine categorized based on the technology development? Name them and identify their
features.

Answer: a) Live video-conferencing Telemedicine Or Real-time telemedicine

Also known as synchronous video, live video-conferencing is a live, two-way interaction between a person and a
healthcare provider using audiovisual telecommunications technology. This kind of telehealth is often used to treat
common illnesses, to determine if a patient should proceed to an emergency room, or to provide psychotherapy
sessions.

Synchronous telemedicine exists as well. It is also known as real-time telehealth and it facilitates real-time
communication between physician and patient. Generally, real-time telehealth solutions take the form of audio and
video communication and replace in-person visits.
Examples of real-time telemedicine:
• Live video and audio conferencing
• Emergency virtual consultations
• Remote follow-up visits

b. Remote patient monitoring (RPM)

RPM also referred to as telemonitoring, allows providers to track and monitor their patients with chronic diseases
(diabetes, hypertension, etc.). RPM solutions equip remote caregivers with vital patient data such as blood sugar or
blood pressure levels so that they can review such data in nearly real time and get notified if a measurement is
abnormal. RPM solutions makes it possible for chronically ill, at-risk or recovery patients to stay at home instead
of being confined to a hospital or clinic.

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 a great extent in senior living in order to prevent falls and monitor the vital health statistics of
residents.
Examples of RPM :
• Glucose trackers
• Wearable devices that track health and fitness levels
• Smart beds that monitors patients‘ health, communicate with hospital devices and equipment and
automatically make necessary adjustments
• Sensors that monitor the gait and balance of patients with walkers and canes

ii) Store-and-forward or asynchronous Telemedicine

• Store-and-forward is involves acquiring medical data (like medical images, biosignals
etc.) and then transmitting this data to a doctor or medical specialist at a convenient time
for assessment offline. It does not require the presence of both parties at the same time.
• Examples of store-and-forward applications:
• Teleradiology solutions that send patient X-rays to another radiologist
• Teledermatology solutions that send patient photos for remote diagnosis
• Telepsychiatry solutions that enable remote behavioral health treatment

Mobile health or mHealth Telemedicine

• mHealth 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.
• Examples of healthcare apps and how valuable they are for senior care.