TELEMEDICINE

BAISHALI DEB
M.Sc. N 1st year
 INTRODUCTION

• The field of medicine during the recent years has made an explosion
in collaboration with the field of technology. In today’s health care
environment, the health care workers have to be flexible, innovative
and informative, able to solve complex client problems by utilizing
the best available resources. For this, newer technologies are being
introduced day by day and it has grown to such an extent that it can
be termed and treated as a separate field.
• One of the major advantages of telemedicine can be for saving of cost and
effort especially of rural patients, as they need not travel long distances
for obtaining consultation and treatment. In this type of scenario,
telemedicine can provide an optimal solution for not just providing timely
and faster access. It would also reduce financial costs associated with
travel. Telemedicine can play a particularly important role in cases where
there is no need for the patient to physically see the RMP.
• With telemedicine, there is higher likelihood of maintenance of records
and documentation hence it minimalizes the likelihood of missing out
advice from the doctor and other health care staff. Conversely, the doctor
has an exact document of the advice provided via tele-consultation.
 HEALTHCARE IN RURAL INDIA
• 70% of India’s population live in rural areas.
• 90% of secondary and tertiary care facility are in cities and towns.
• Low penetration of healthcare services.
• Lack of investment in health care in rural areas.
• Inadequate medical facilities in rural areas.
• Problem of retaining specialist doctors in rural areas.
 HISTORY OF TELEMEDICINE

The beginning of telehealth have existed through primitive forms of

communication and technology. The exact date of origin for
Telehealth is unknown, but it was known to have been used during
the Bubonic Plague. During that time, they were communicating by
heliograph and bonfire. Those were used to notify other groups of
people about famine and war. In the early 1900s, people living in
remote areas in Australia used two-way radios, powered by a
dynamo driven by a set of bicycle pedals, to communicate with the
Royal Flying Doctor Service of Australia.
• The practice of Telemedicine officially started first at Boston, USA in
1967.
• In India, telemedicine practice was initiated at Lucknow and
Chennai at 1997. In Kerela, the first unit of telemedicine was
established at Medical College Trivandrum in 2003. The first
Ayurvedic telemedicine center was established in India in the year
2007 by Partap Chauhan, a well known Indian Ayurvedic doctor.
 DEFINITION
• The European Commission’s health care telematics program defines
telemedicine as: ‘Rapid access to shared and remote medical expertise by
means of telecommunication and information technologies, no matter
where the patient or relevant information is located.’
• According to WHO ‘The delivery of healthcare services, where distance is
a critical factor, by all healthcare professionals using information and
communication technologies for the exchange of valid information for
diagnosis, treatment and prevention of disease and injuries, research and
evaluation, and for continuing education of healthcare providers, in the
interests of advancing the health of individuals and their communities.’
• TELEHEALTH- Telehealth is defined as ‘the use of electronic
information and telecommunication technologies to support long-
distance clinical health care, patient and professional health related
education, public health and health administration.’
Telehealth encompasses telemedicine, tele-nursing and tele-
education.

• TELE- EDUCATION: It is the application of information and

communication technologies in the delivery of distance education.
• TELE-NURSING- Tele-nursing is the subset of tele-health in which the
focus is the nursing practice via tele communication. It also refers to the
use of information technology in the provision of nursing services
wherever physical distance exists between patient and nurse, or
between any number of nurses.

• REGISTERED MEDICAL PRACTITIONER (RMP)- RMP is a person who is

enrolled in the state medical register or the Indian medical register
under the Indian medical council act, 1956.
 PRINCIPLES OF TELE MEDICINE
• Telemedicine applications and sites should be selected pragmatically, rather than

philosophically.

• Clinician drivers and telemedicine users must own the systems

• Telemedicine management and support should be from the ‘bottom up’, rather than from

the ‘top down’

• The technology should be user friendly.

• Telemedicine users must be well trained and supported, both technically and

professionally.

• Telemedicine applications should be evaluated in a clinically appropriate and user-friendly

manner.

• Information about the development of telemedicine must be shared.

 TYPES OF CONNECTIVITY
•ONE PATIENT CONNECTED TO ONE
1. DOCTOR.
POINT TO •WITHIN SAME HOSPITAL.
POINT

TELEMEDICINE: 2. •ONE PATIENT END AT A TIME

POINT TO CONNECTED TO MANY
MULTI SPECIALIST DOCTORS .
WAYS OF
POINT
COMMUNICATION

3. •SEVERAL PATIENT ENDS CONNECTED

MULTI- TO SEVERAL DIFFERENT SPECIALIST
POINT TO DOCTORS.
MULTI- •AT DIFFERENT HOSPITALS, IN
POINT DIFFERENT GEOGRAPHICAL DISTANCES
GUIDELINES FOR TELEMEDICINE IN INDIA

• Seven elements should be considered before any telemedicine

consultation-
1. Context.
2. Identification of the RMP and the Patient.
3. Mode of communication.
4. Consent.
5. Type of consultation.
6. Patient evaluation
7. Patient management
TOOLS FOR TELEMEDICINE

1. According to the Mode of Communication-

1. VIDEO

2. AUDIO

3. TEXT BASED
2. According to timing of information transmitted-

1. REAL TIME VIDEO/AUDIO/TEXT INTERACTION

2. ASYNCHRONOUS EXCHANGE OF RELEVANT

INFORMATION
 3. According to the purpose of the
consultation-

1. First consult with any RMP for diagnosis/

treatment/ health education/ counseling.

2. Follow-up consult with the same RMP

 TYPES OF CONSULTATION

Follow-Up Consult(s)
- The patient is consulting with the same
First Consultation
RMP within 6 months of his/her previous
- The patient is consulting with the RMP for
inperson consultation and this is for
the first time; or
continuation of care of the same health
- The patient has consulted with the RMP
condition. However, it will not be
earlier, but more than 6 months have lapsed
considered a follow up if:
since the previous consultation; or
- There are new symptoms that are not in
- The patient has consulted with the RMP
the spectrum of the same health condition;
earlier, but for a different health condition
and/or
- RMP does not recall the context of
previous treatment and advice
4. According to the individuals involved-

Patient to RMP

Caregiver to RMP

Health worker to RMP

RMP to RMP
INITIATION OF TELEPSYCHIATRY CONSULTATION BY A FAMILY MEMBER WITH PATIENT

Initiation of telepsychiatry consultation by a

family member with patient

Check ID of the patient and age proof

Check ID of the family member and a verified document
establishing his/her relationship with the patient

For Children (less than 16years)

For adult patient continue as per
Telemedicine Practice Guidelines

Assessment of Mental Capacity (MHCA, 2017

Sec 81) on video consult by a psychiatrist
 Assessment of Mental Capacity (MHCA, 2017 Sec 81) on video
consult by a psychiatrist

Capacity to consent present Capacity to consent absent

Take consent from patient and ask if he/she feels In-person consult to be
safe and comfortable to consult in presences of advised for all first
family members. consult
Continue as per Telemedicine Practice Guidelines
For both first consult and follow-up consult

Follow Advance Directive/ Take consent

from Nominated Representative

Continue as per tele-follow

In-person consult
consult
INITIATION OF TELEPSYCHIATRY CONSULTATION
BY A FAMILY MEMBER WITHOUT PATIENT
Initiation of telepsychiatry consultation by a
family member without patient

In-person consult to be
Tele-follow-up consult
advised for all first consult

Check for authorization letter, valid ID and

verified document establishing his relationship

If no proper documents
Continue as per tele-
advice In-person consult
follow consult
with patient
INITIATION OF TELEPSYCHIATRY CONSULTATION BY A
HEALTHCARE WORKER
Healthcare worker in a community setting

Check for patient’s ID, Age, Address and so forth

Assess Capacity to Consent for treatment

Capacity to Consent Present Capacity to Consent absent.

Check for advance directive and
follow it
Consented for Not Consented for
telepsychiatry telepsychiatry

Initiate the telepsychiatry

consultation with Stop the consultation
psychiatrist
 No advance directive. Take
consent from the nominated
representative

Initiate the telepsychiatry with psychiatrist & follow the

Mental Healthcare Act, 2017 to provide care under Sec 94 or
100 or 101 or 102 or 103 or 104 (whichever is appropriate) or
plan for in-person consult or complete the consult
STRENGTHS AND LIMITATIONS OF VARIOUS MODES OF COMMUNICATION
MODES STRENGTHS
VIDEO - Closest to in person consult.
- Patient identification is easier
- RMP can see the patient and discuss
with the caregiver
- Visual cues can be perceived
- Inspection of patient can be carried
out
AUDIO - Convenient and fast
- Unlimited reach
- Suitable for urgent cases
- No separate infrastructure required
- Privacy ensured
- Real-time interaction.
LIMITATIONS
-Is dependent on high quality
internet connection at both ends
- Since there is a possibility of
abuse/ misuse, ensuring privacy
of patients in video consults is
extremely important.
- Non-verbal cues may be missed
-Not suitable for conditions that
require a visual inspection
- Patient identification needs to
be clearer
MODES STRENGTHS
TEXT BASED - Convenient and quick
- Documentation & Identification
may be an integral feature of the
platform
- Suitable for urgent cases, or
follow-ups, second opinions
provided RMP has enough context
from other sources,
- No separate infrastructure
required,
- Can be real time
ASYNCHRONOUS: - Convenient and easy to document - Not a real time interaction
Email, Fax,
recordings, etc - No specific app or download
requirement
- Images, data, reports readily
shared
- No separate infrastructure
required
- More useful when accompanied
with test reports and follow up and
second opinions
LIMITATIONS
- Besides the visual and physical
touch, text-based interactions
also miss the verbal cues
- Difficult to establish rapport
with the patient.
- Cannot be sure of identity of
the doctor or the patient
- Patient identification is
document based only and
difficult to confirm
- Non-verbal cues are missed
- There may be delays because
the Doctor may not see the mail
immediately
 EMERGENCY SITUATIONS:

• In all telemedicine consultations, as per the judgment of the RMP, if

it is an emergency situation, the goal and objective should be to
provide in-person care at the soonest.
• The RMP, based on his/ her professional discretion may
1. Advise first aid
2. Counseling
3. Facilitate referral
SPECIFIC RESTRICTIONS IN
PRESCRIBING MEDICINES
ONLINE IN PSYCHIATRY

• List O
• List A
• List B
• List C
METHODS OF TRANSMISSION IN TELEMEDICINE:

1. Technology involved
– Real time or synchronous
– Store and forward or asynchronous telemedicine.
2. Application adopted
– Telepathology
– Telecardiology
– Teleradiology
– Telesurgery
– teleophthalmology
 APPLICATIONS OF TELEMEDICINE:

• Telehealth care: It is the use of information and communication technology

for prevention, promotion and to provide health care facilities across a
distance. It can be driven in the following activities:
– Teleconsultation
– Telefollow-up

• Tele-education: Tele-education should be understood as the development of

the process od distance education (regulated or unregulated), based on the
use of information and telecommunication technologies, that make
interactive, flexible and accessible learning possible for any potential recipient.
• Disaster management: Telemedicine can play an important role to provide
healthcare facilities to the victims of natural disasters such as earthquake,
tsunami, tornado, etc. and man made disaster such as war, riots, etc. During
disaster, most of the terrestrial communication links either do not work
properly or get damaged so a mobile and portable telemedicine system with
satellite connectivity and customized telemedicine software is ideal for
disaster relief.
• Telehome health care: Telemedicine technology can be applied to provide
home health care for elderly or underserved, homebound patient with chronic
illness. It allows home health care professionals to monitor patients from a
central station rather than travelling to remote areas chronically ill or
recuperating patients for routine check-ups.
 ADVANTAGES OF TELEMEDICINE:

• Eliminates distance barriers and improve access to quality health

services.
• In emergency and critical care situations were moving a patient may
be undesirable and or/ not feasible.
• Facilitates patients and rural practitioners’ access to specialist
health services and support.
• Lessens the inconvenience and/or cost of patient transfers.
• Reduces unnecessary travel time for health professionals.
 BENEFITS FOR PATIENTS:

• Facilitates patients and rural practitioners’ access to specialist

health services and support.

• Lessens the inconvenience and/or cost of patient transfers.

• Early detection of diseases.

• Saves work loss time and increases productivity.

• Home health care

 BENEFITS FOR DOCTORS:

• Excellent opportunity to share knowledge between physicians

all over the world.
• Joint consultation with expert physicians and surgeons for the
better management of complicated cases.
• Local doctors can be updated anytime.
• Medical education in form of teleconference.
 BENEFITS OF GOVERNMENT:

• Reduced rush to medical facilities in cities.

• Improved monitoring facilities at rural centers.
• Increased reliance on government health care system.
 CHALLENGES:
• Low bandwidth- neither telephone lines nor electricity in rural areas
• Unstable electricity supply.
• Patient’s fear and unfamiliarity.
• Financial unavailability.
• Lack of basic amenities.
• Literacy rate and diversity in languages.
• Quality aspect.
• Government support.
• Perspective of medical practitioners
 GOVERNMENT INITIATIVES:

• DEPARTMENT OF INFORMATION TECHNOLOGY (DIT) has taken

initiatives for development of technology, initiation of pilot schemes
and standardization of telemedicine in the country.
 Telemedicine module for tropical medicine in West Bengal-Webel
(Kolkata), IIT, Kharagpur and School of Tropical Medicine Kolkata.
 Telemedicine and telehealth education facilities in Kerela—3
specialty hospitals with 4 district/rural hospitals.
 Telemedicine network (CME program) for Naga Hospital, Kohima with
Apollo Hospital, Delhi.
 ESANJEEVANI OPD

• The Ministry of Health and family welfare have launched a new portal
through which the people will be able to take teleconsultation services
and have proper coverage of their health. The main objective of E
sanjeevani OPD is to provide health advice to individuals with the help of
digitalization who are finding it difficult to visit hospitals.

• Services Available At E Sanjeevani OPD Portal

 Online OPD
 Real-time telemedicine
 State services doctors
 Video consultation
 Chat
 Free services
• STEPS FOR CONSULTING:

1. Verify your mobile number.

2. Generate token after registration.

3. Log in after getting notification.

4. Wait for your turn and consult doctor.
5. Download e-prescription.
 TELEMEDICINE IN LGBRIMH:

• Who can consult?

 Registered patients of LGBRIMH
 Any new patient through a medical officer.

• Requirement for Tele-Consultation:

 In person consultation in last 6 months for LGBRIMH patients.
 Access to any internet enabled device with camera.
• How to proceed?
- Call or email for appointment.
- Send the old prescription for old UHID No.
- Text message the following:
- Name and relation of the caller, name of the patient, and the
purpose of the consultation.
- Connect through video and get live tele-consultation
- Download the prescription

*For Appointment: Phone no. 9531205260, email id-

lgbtelemed@gmail.com
* Timing for appointments: MONDAY to SATURDAY- 9am to 2 pm.
 CONCLUSION
• Telemedicine is following the trend of the technological advancements of
recent years, providing a service that the patients can access in the palm
of their hand. It eliminates the back and forth travelling between the
hospital and home which reduces the cost of travel expenses. It is an
emerging information and communication enabled health technology
which has the potential to facilitate access to healthcare in
underprivileged population into existing healthcare delivery system.
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