Telemedicine seems to be the cheapest way to bridge the urban- rural divide in access to health care in India. Telemedicine has been successfully inplemented in many villages in India, but it is only the tip of the ice berg. India being a Hub of IT, there is very good scope for further growth of telemedicine, with support of greater technology, standardization and regulations. Making tele-healthcare more accessible is possible only by the active involvement of all stakeholders Government, hospitals, Technology providers, Support staff, Educational & Research Institutes, Insurance, Financiers and Patients

1. Telemedicine in India
Manisha Iyer, Nikhil Dev, Jose K Joy
Information & Interface Design
Guide: Dr. Bibhudutta Baral

2. Telemedicine in India: Introduction
Need for Telemedicine
Village Population
Doctors in Villages
Rural Population
Doctors in Urban areas
Doctors in Semi Urban
Telemedicine is the use of information communication technology for the delivery of
health care services to areas where public health services are below the required levels. It
has enormous potential for increasing the access to medical services by increasing the
reach.
In India with 75% of the Indian population live in villages. But 75% of the doctors
practise in Urban areas, 23% in Semi Urban areas and only 2% percent of the doctors in
villages where 75% of the population lives. All incentives to to entice the doctors to serve
in the rural areas have failed. This inequitable health scenario in India
Telemedicine in India uses broadly two types of technology- the store and forward technology, where the patient information is stored and sent to the Specialist centre where
the specialist doctor gives his diagnosis. And the real time streaming where a video
conference is used to provide live consultations by Specialists to patients in remote areas.

4. Remote Consultation
& Critical Care
Monitoring
Home Care
&
Ambulatory
Disease
Surveillance &
Program
tracking
Telementored
procedures/
Surgery Robotics
Telemedicine
Application
Continuing
Medical
Education &
Public Awareness
Disease
Management
Second Opinion &
Complex Interpretations
Disaster
Management

5. Review of Literature
Introduction:
From our primary research on healthcare we found that telemedicine was an upcoming field in India and could play a major role in making
healthcare accessible and affordable. It involves a lot of interaction
between people and technology, and we wanted to enquire into the
interaction and delivery of the service, to find design opportunities for
improving the same.
For this purpose we needed to have a thorough understanding of
the current scenario. We did some googling and found our starting point
at www.telemedindia.org. This site is maintained by School of Telemedicine and Biomedical Informatics, SGPGIMS, Lucknow, India and SONY.
This site gave a very good overview of what tele-medicine is, about
equipments and softwares, Telemedicine initiatives by the Govt and
others, Policies and Guidelines etc. It also give us some important cues on
the implementing agencies- ISRO implementing the largest telemedicine
initiative in the country covering more than 200 rural & district hospitals,
Apollo’s Telemedicine Network Foundation, Narayanayala Hrudhayalaya’s
telemedicine network etc, Shankar Netralaya’s teleophthalmology
network etc.

6. Home Health Care via Telemedicine
B2BMedia IncInterview with Dr Mahmud oncologist & CEO of American TeleCare:
Home telehealth: the future of home care
Shereene Z. Idriss Partners Telemedicine
"Personal Telemedicine System" (PTS) for the home- is organized around two modules:
the home unit and the nursing unit.
- The nursing unit is set up at a central nursing station, and is staffed by a nurse
who
provides electronic housecalls to multiple home units.
- The system works over the "plain old telephone system" (POTS).
-Thus, it operates over the ubiquitous analog phone lines, making it universally
avail
able
POTS seems the best for making the facility accessible. Its bandwidth capacity is very
less an cannot be used for real time teleconsultations, so it is best suited to transmit the
vital stats. Dr Mahmud strongly feels that though it cannot be used to examine small
wounds, the resolution of the video available for POTS is sufficient for the nurses to
understand the mood and response of the patient which is sufficient for monitering
patients with chronic diseases which account for the majority of patients who demand
homecare. The high cost of the patient unit makes this very biased to those who can
afford it. At the same time we observed from our research that ReMeDi is a very low
cost telemedicine kit which is more affordable for users.
What ever said and done, telemedicne in home care has its undeniable benifits- there hve been proven decrease in disease progression, and it ensures to some
extent that the patients’s problem does not accumulate between visits to the doctor.
An Interview with Lisa Remington (5-year veteran of strategic planning and business
development for the home-health industry):
According to Lisa Remington, telemedicine is the future of the home health
industry. “Since we are aging as a society, and since aging people require more health
care, I think it is fair to say that the only way to make the shrinking dollars fit the
increasing needs is to become a lot more efficient. Telemedicine is the only thing I see
coming up that promises real improvements in efficiency.” and she also states that “ the
evidence I’ve seen suggests that the personnel savings will be much, much greater
than the technology costs.”
We feel the only way personal saving in healthcare can be increased is by more contribution by the Govt in the public healthcare expenditure.
Need for home-telehealth/ Connected health:
- To make health care accessible to the elderly and patients who cannot
travel.
- Increasing costs of hospitalization
- Shortage of health care providers
- For management of Chronic diseses like diabetes
Besides the above mentioned reasons in the article we found the following also to
be the need for connected health:
- Proving timely care
- Making patients more involved in their own Helth (Self Management)
- Home environment speeds recovery
- Travelling in traffic takes too much time these days
Two approaches for remote monitoring used, mentioned here is the telephone
and telemonitering.
In the first approach, a nurse replaces the in-house visit with a weekly
telephone call, during which the nurse reviews the patient’s status, and counseling
and educational support are offered to the patient. The challenge that has
surfaced with this system is the reliability of patient self reporting.
In the telemonitoring method, Daily measures of body weight and blood
pressure are recorded via sensors, which transmit the data wirelessly to an interface unit in the patient’s home. The information is then transferred to central
servers for further evaluation by the patient’s healthcare provider. Patients can
connect with their healthcare provider through email, and some offer videoconferencing capabilities so that patients and physicians can hold direct teleconsultations.
We feel, this scheme is highly technology based, and needs a little getting
used to by any elderly user. Using wearable sensors which monitor the vital stats
continuously is another option which can get irritating and uncomfortable at
some point.
Thus we feel this technology would best suit for a short duration and would not be
very well suited for constant use.

7. Economics of Telemedicine
by Dr. D Lavanyan, MBBS,MD CEO & MD, HCIT Consultant
This paper compares the cost of telemedicine to the costs of conventional
methods of health care. People are not aware of the cost effectiveness and the
efficiency of the telemedicine. Telemedicine in most cases is assumed to be
having no outcome on the health. It explains the other factors due to which the
people resist to start practicing the telemedicine.
Requirements of Telemedicine are:
IT hardware, Software, Media hardware, Medical hardware, Internet Connectivity,
Infrastructure, Man ware.
The cost to start a telemedicine set up is 50,000 which is very less compared to
that spent for the equipments in the hospitals (millions). So cost of incorporating
telemedicine is affordable comparatively.
Technology is no longer a barrier. Internet connectivity is there in all
geographical regions of India through satellite. The benefits of telemedicine are
already proven in many places. The thing is that nobody takes initiative due to
certain factors as below.
The goals set up before starting a telemedical set up are:
Political gain, Improved quality of care, Business profit
Key considerations :
Visible are -
Quality of care , Patient safety, Patient satisfaction, Practitioner
productivity, Practitioner satisfaction, Financial return, process.
Invisible are - Political need, Social need, End user indulgence, Staff indulgence,
Inter/intra departmental politics.
Cost factors:
Visible –
Unseen –
hardware, software, connectivity, man ware, training, operational
management, support.
Lobbying, publicity, misuse, damage.
Thus nobody takes risks to start the centres which may become a
burden to them due to the management failure as well as the external
factors as mentioned above.
Few telemedicine centres started in India stopped working after
five years. These were setup only for the political gain of the MLA or the
government. Government pays to set up the centre. Some private
hospitals provide services and consultations. Patient gains improved
quality of service. Government gains good publicity. After five years the
ruling party changes and thus it won’t get any support further.
Has it been good for the economy of that village for that five
years? Yes. But has it made any profit for the telemedical centre or the
system? No.
A good business plan can make money through telemedicine.
Then there may be a lot of people taking initiative to start centre and all.
The model can be:
technology based model
implementation based model or a
business based model.
Adopting cost effective or innovative solutions can attract the
service providers. A patient spends a lot of money in a speciality hospital. If a nursing home near to his home can provide the same service
through telemedicine he would definitely prefer this option. He feels
comfortable and is cost effective. Support with bank loans, extending
the hand hold period etc. can be tried in a business model. So an
effective model can solve the problems in the existing system of
telemedicine in India.

8. “Telemedicine: A New Horizon in Public Health in India” by
Aparajita Dasgupta, Soumya Deb
Telemedicine Concepts
- Telemedicine Consultation centre(TCC)
TCC is the site where patient is present. Here all the
equipments for scanning and communicating the patient’s
medical information is present.
- Telemedicine Speciality centre(TSC)
Is the site where the specialist is present
- Telemedicine System
- Hardware
-computer
-printer
-scanner
-video conferencing equipment
- Software
Enables aquisition and processing of the patient
information
-Communication Channel
The paper “Telemedicine: A New Horizon in Public Health in India”
by Aparajita Dasgupta, Soumya Deb gave a lot of relevant definitions
relating to telemedicine such as Telemedicine Consultation centre ,
Telemedicine Specialty Centre (TSC), Telemedicine System and also
described the two types Technologies used :
- Store and Forward
- Real Time
which were mentioned in almost all Literatures.
Regarding Telemedicne Infrastructure, The Telemedicine Centres are
classified as:
Primary Telemedicine Center (PTC)
Secondary Telemedicine Center (STC)
Tertiary Telemedicine Center (TTC)
The Telecommunication Technologies in use as mentioned were T-1, ISDN, POTS
and Internet, but we observed that T-1 is quiet unheard of in India, and internet facility is
available only in urban and semi urban areas. Whereas Plain Old Telephone Service, since
it can have only 56kbps, can support only store and forward and cannot be used for real
time tele-health.
The paper presented various applications in Public Health, which we did not
come across in other literature studies, in Epidemiological Surveillance & in Interactive
health communications and disease prevention.
“It (telemedicine) can give new insight into geographical distribution and gradients in disease prevalence and incidence and valuable insight into population health
assessment.”
“It can play a pivotal role in anticipating epidemics.” This can be possible by studying the electronic medical records of the population and make a combined assessment of
the health of the society.
“Information technology and telemedicine can be used to inform, influence and
motivate individuals and population organizations on health, health-related issues and
adoption of healthy lifestyles. ”
It promotes self-care and domiciliary care practices”,
”It can be a very important tool for the evaluation and monitoring of healthcare
services.”
A key point in under Telemedicine in India section was that about the Failure of all incentives for specialists to practise in rural areas. This we felt was the major cause for the inequity of healthcare in India.Current Efforts (was as mentioned in the telemedindia.org web
site) are supported by Govt: DIT, ISRO NEC, private : Apollo, Narayana Hrudhayalaya, State
Govts, other private organizations,Initiatives by DIT, C-DAC software, and a detail of ISRO’s
Network is again mentioned.

9. Technology Critical Issues in Medical Education and the Implications for Telemedicine
by Ashok Kumar Mahapatra, Saroj Kanta Mishra, Lily Kapoor, Indra Pratap Singh - School of Telemedicine
& Biomedical Informatics,Sanjay Gandhi
Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, INDIA
SGPGIMS is a medical college in Lucknow practising distance medical education
through their telemedicine network for last ten years. SGPGIMS Telemedicine
Program is using various kind of high bandwidth communication network such as
satellite based communication provided by ISRO, Lease line through terrestrial fibre
optic network and Integrated Services Digital Network (ISDN) to connect the district
hospitals in rural and remote hilly areas, medical colleges and tertiary level hospitals
for medical knowledge exchange. The process has started in September 2001 and is
continuing in steady pace. Encouraged with active participation by the stake
holders, SGPGIMS has been expanding its telemedicine network with willing
partners across the country and South Asian region aiming at bridging the knowledge and skill gap among students, teachers, practitioners, public health and
paramedical professionals involved in healthcare at tertiary, secondary and primary
level.
SGPGIMS carried out 1309 tele education sessions between 2001 to 2009 for
training and teaching of the students, medical teachers and practicing doctors. The
tele education modules practiced are
Tele-education for postgraduate students of medical colleges,
Tele-education for district hospital doctors,
Training of Medical Professionals and skill transfer (Tele-mentoring),
Tele-CMEs (Continuing Medical Education).
In India most of the tele-educational activities are running in
project mode. Very few medical colleges / institutes like SGPGIMS
Lucknow, AIMS Kochi, CMC Vellore, PGIMER Chandigarh, SRMC Chennai, AIIMS New Delhi have now integrated this mode of knowledge
exchange into their routine educational program at postgraduate
level.
The emerging technologies like virtual reality, telepresence,
simulation based skill development will increase the scope of medical
education and thus the service. The technical ministries of the government took the initial lead e.g. Department of Information Technology
(DIT), Ministry of Communication and IT, Indian Space Research
Organization (ISRO) carried out the pilots by providing the technology
and funding the projects. Corporate hospitals also made investments
in tele-health infrastructure e.g. Apollo Telemedicine Network Foundation, Chennai by the Apollo Hospital group, Narayana Hrudayalaya,
Bangalore etc.
Telemedicine is basically providing service to remote areas
using the electronic information and telecommunication technologies. It makes services accessible and affordable. Thus there is a great
need of medical professionals and doctors who can handle the technology. The future of health care may be better through telemedicine.
The institutes like SGPIMS have long vision and are providing medical
education on telemedicine. Thus such initiatives should be given funds
and assistance from the government and should be highly appreciated.

10. Mobile Telemedicine using Data Grid
by Sriram Kailasam, Santosh Kumar, and D. Janakiram
This paper discusses the recent advances in the mobile
broadband technology, context-aware, P2P data grid framework
for mobile telemedicine. It also gives a clear picture of the
usability of wireless technologies in telemedicine systems.
First of all, the paper discuses about the current telemedicine
system and its applications as discussed earlier. As the number
of telemedicine units increases, the centre at the big hospital
may become a bottleneck. The privacy also can be an issue. The
main challenge of the system is the problem with involving
patients during emergencies. The main problem faced by
patients is the difficulty in travelling to the hospital and back.
Then it discusses about the mobile technologies such as Wi-Fi,
WiMAX, Bluetooth and ZigBee. How to make an interaction
between medical sensors and communicating will be a big
problem.
The doctor will be equiped with a mobile phone or PDA
which is capable of receiving wireless medical information like
ECG and other imaging. There will be a pre-configured software
installed in the mobile which can schedule incoming signals and
interrupt doctor accordingly. By integrating health insurance,
blood banks, ambulance etc. into the grid, we can make a
full-fledged health grid covering the entire country that can
provide a whole lot of medical services. Such a health grid will
be of immense help to the developing nations.

11. Research Methodology
Abhay Singavi, CEO
NarayanaHrudhyalaya
Sister Greta,
HomeCare, Manipal Hospital
NandhkishoreDhomne, CIO,
Manipal Hospitals
Implementation
Experts
Khemchandra Birhade,
Vice-President,
Business Development,
NeuroSynapics
Technology/
Equipment
Expert
Sources
Pradeep, Telemedicine Dept,
Apolllo Hospitals
Ms Shiney, Manager,
HomeCare, Manipal
Hospital
Technonlogy Users
End Users
Mr. Jagdeesh, Patient,
Apollo Hospital
Mr. Roy, Patient,
Apollo Hospital
Lakshman, Telemedicine Dept,
NarayanaHrudhayalaya
From our literature review we found out Apollo, Narayana Hrudhayalaya
and Manipal hospitals were the biggest telemedicine implementers in India. We
realized these places would give us a real picture of Telemedicne in India, and
decided to base our research on them.
As we did not have any contacts we spent a lot effort in finding resourceful links. We sent e-mails and made appointments. Many of whom we met
(especially Mr Abhay Singavi CEO of Narayanaya Hrudhyala )were CEOs and CIOs,
and were able to share great insights into the working of Telemedicine that we
could not have found anywhere else. They had very good knowledge about the
subject and were very passionate about it, and were happy to share their knowledge with us. Meeting those people not only have us a better understanding of
the subject, but also really motivated us and brought in a sense of purpose behind
the research. Narayanaya Hrudhyala has the world’s largest telemedicine network
and they provided this service absolutely free of charge.
They adopted a lot of innovative delivery models which was very cost efficienteg) they made use of the Postal service to deliver medical reports at the doorstep of
every individual! It was an inspiring meeting!!! Form his interview we located a few key
areas in telemedicine delivery in India where not much had been explored- icu monitoring, ambulance monitoring and mainly homecare telemedicine where patients could
have access to health care from their homes, this as they identified could also help in
reducing the hospitalization time and provide the comfort of home to the patient. This
becomes a win-win situation for both parties.
Now that we had some expert opinion, we wanted to approach the patients and
clinicians whom formed the End Users of this technology. Here we faced some difficulty
as Bangalore being a metropolitian city, has hardly any villages. The rural areas, where
the telemedicine end users were located were too far away for us to access. But after
some more research we were able to locate local patients and were able to interview
them.
We also approached other stakeholders and service providers. We tried contacting ISRO, C-DAC, CISCO and others but with little success. We contacted NeuroSynaptics
which turned out to be a goldmine of a resource. They were experts at manufacturing
low cost innovative telemedicine technology. Though they were initially quiet hesitant
about sharing their work, in the end they really opened up and shared with us their they
methodology and procedures. From NeuroSynaptics we understood the shortcomings
in the existing system of Telemedicine delivery which we could not find in any literature.
We understood that in India there is very little Direct doctor to patient telemedicine
services- almost everywhere the patient must go to clinic where there is a clinician or a
general physician who connects the the patient to the remote specialists over telemedicine. There is very little being done in Home based Telemedicine where there is direct
connection between the patient and the service provider- This was the same view that
Narayanaya Hrudhyala also had.
Thus this overlap of “need for attention in HomeCare Telmedicine” gave us a direction to
focus our research on the same.
Thus we started out again on a whole new literature study on HomeCare
Telemedicine in India. Since this concept was only emerging in India there are not many
papers from India, but we read up papers from other countries and found that many of
the existing methods and models there can be easily adapted and brought into the
Indian context, at least for the urban areas of the country where technology has
penetrated reasonably well. These models can be revamped in forthcoming iterations
to suit the rural areas too.

12. TeleMedicine at Apollo Hospital,Banglore
Apollo Hospital
From our interview with Mr. Praveen Kumar, we understood that in Apollo Hospital Bangalore, Telemedicine is happening only within the Apollo Group of Hospitals. We realized that
Telemedicine is not just used for the benefit of rural areas but also to facilitate intra hospital medical
networking.
Since the facility is available only to patients who come to the hospital, the reach of its service is not
as much as it could have been if they had dedicated telemedicine centres spread across the city, or
even better, the villages. Since Apollo itself is a speciality hospital, there hardly arises any circumstance where one needs more speciality care, thus Telemedicine has hardly any role to play. Because
of this there is no dedicated department for Telemedicine.
Apollo Hospital
Apollo Hospital
Generally the only occasion where a patient uses a telemedicine service is when he has
relocated from his home town and wants to meet his family doc back in town. Instead of travelling
all the way back to his home town, he could just visit the same hospital group in his current location
and request for telemedicine consultation with his family doc. This way he saves a lot (time, effort
and money) on travel.
Tele-consultations and tele-diagnosis are being given in almost all medical fields and Mr
Praveen observes that tele-neurology has the most takers. They have simple procedure of going
about it: When a patient requests a telemedicine session, the telemed dept gets an appointment for
him. A day before the appointment, the patient records are emailed to the concerned doctor. The
patient is expected to report half an hour before the appointment.(Apparently they don’t support
Emergency care!) The technician establishes the connection with the other centre which is online.
Once the connection is established, the patient can see the doc on the screen and speak to him real
time and get medical advice.
Apollo hospitals all over use the PolyCom Vedio conference services as it the most economical of all the choices available in the market today. It is connected across by ISDN or by Static IP.
During the tele-consultation, if the doc prescribes some tests, it is locally performed and the results
are sent to the doc over email system separately. Even the patient records and files are sent seperatley to the doc by the records department over the internet. The prescription prescribed the doc
again is faxed or email separately. (Here we perceived an opportunity to integrate all these related
individual tasks such that all of them can be performed by the same Telemedicine equipment. ) The
patient is charged as much as for the Tele-consultation as the regular consultations. Although Apollo
Banglore does not have
associations with other hospitals or health clinics, there have been some tele-consultations
provided to some centres in Iraq , Nigeria and Mauritius

13. Telemedicine Initiative at Narayana Hrudhayalaya
Mr. Abhay Singavi, CEO, Head of Telemedicine dept, Narayana Hrudayalaya
The main idea behind Narayana Hrudayalaya’s initiative on
telemedicine,according to Abhay Singav, is that, “less than 1% of the sick
requires an operation, if you do not need to operate, you don’t need to touch
and if you don’t need to touch, you don’t need to be there and the best
solution for this would be Tele-consultation through telemedicine. More over
1768:1 is the patient:doctor ratio in India.”
The main functional areas of Apollo hospital telemedicine are, Teleconsultation, TTECG, Tele-education, Hrudaya Post, Mobile Van and PAN
African e-Network.
Patient requiring specialist consultation in remote center can interact directly
with the specialists through video conferencing. If he needs further proceedings only, he will be asked to come to the specialty hospital. Till date, they did
more than 30000 tele-consultations. ISRO is providing the satellite links with
free of cost for this service. West Bengal, Karnataka, North-Eastern States,
Andaman & Nicobar Islands, Jharkand, and Gujarat, Malaysia, Tanzania, Nigeria,
Burundi, Zambia, and Bangladesh are the major focus areas.
TTECG: This project is mainly for village hospitals deficient of cardiac
support.They found out that the Telephone network and the Indian Post office
networks as the most connected networks in this country and they connected
308 centers in India as well as abroad to their network of TTECG which is the
world’s largest ECG network connectingTanzania, Afghanistan, Pakistan,
Bangladesh, Mauritius and Malaysia.
CME-Tele education: They are using the tele-medicine facility to conduct
academic teaching / training sessions. They have found that telemedicine
proved to be effective in establishing communication not only between the
patient & the physician but also between the teacher and the students.
“Less than 1% of the sick requires an operation, if you do not need to operate, you don’t
need to touch and if you don’t need to touch,
you don’t need to be there and the best
solution for this would be Tele-consultation
through telemedicine. More over 1768:1 is the
patient:doctor ratio in India.”- Abhay Singavi,
CEO Preventive Health, NH
Hrudaya Post: India has world’s largest network of post officesand most these
post offices have very good connectivity including telephone connections,
Internet and broadband.
Through Hrudaya Post, their aim was to link all the post offices to the hospital, so that heart patients living in small town and villages can go to any of
the post offices and send their entire medical reports to them by scanning
the medical reports and once the report reaches the hospital, their heart
specialist will go through the entire file and give the opinion. This opinion
goes back to the concerned post office and this will be delivered to the
patient. Now they are running this project successfully in 25 post offices in
Karnataka.
Mobile van: They put all the machines in a large van, is which an Echo
Machine, Thread Mill, ECG’s, defibrillator. This bus goes to the villages and
meet patients, who only require to procedure its needs, ask to come to
Narayana Hrudayalaya. Now they are trying to link the mobile unit to their
specialty centers in Bangalore with the satellite link from ISRO.
PAN African e-Network: Govt. of India and the Ministry of External Affairs
made use of the Pan-African e-Network. The network would primarily
provide e-Services with priority on Tele-education, Tele-medicine services,
and VVIP Connectivity. Narayana Hrudayalaya is connected to 53 city states
of Africa and is actively delivering the health care to great number of people
through the aid of TCIL’s channel.

14. Telemedicine Initiative at Narayana Hrudhayalaya

15. Telemedicine Initiative at Narayana Hrudhayalaya

16. Telemedicine at Manipal hospital, Bangalore.
The Manipal Hospital Telemedicine Network works upon a “server
based technology” the server is situated in Bangalore.
-
All the peripheral hospitals end and user end are given a login ID
through which all the members are able to get the telemedicine
consultation through this network.
-
Currently they are using ISDN connections. High speed data cards
are been used for teleconference. These consultations will be
provided by Manipal Hospital, Bangalore on a scheduled basis,
which will be coordinated by team of professionals.
-
Here the secondary and tertiary level of telemedicine is usually
done. The patient comes to the hospital. If the doctor finds it
difficult to carry the case, he consults with the the specialists in a
remote area through the telemedicine network.
-
Post and presurgery teleconsultations are done.
-
No live take overs.
-
Also the doctors in this hospital gives assistance to the hospitals
through video conferencing. They do 10 to 12 sessions per week.
-
The telemedical proceedings in manipal hospital, bangalore are
not very active even if it is a multi speciality hospital.
“Half the disease is cured when the
patient just gets the doctor’s touch
which is not really possible in telemedicine.”
“We are still waiting for better Technology and bandwidth- 3G will definately help”
-Nandakishore Dhomne, C I O, Manipal
hospital, Bangalore.
The discussion was helpful as he told us about the technological deficiencies in Indian context:
- Video conferencing is not effective in case of surgery
due to the poor Internet speed. The satellite connections
available are not effective due to a latency of 530 ms
minimum.
- The image transfer should be instantaneous.
- High definition video is needed for telesurgery.
- VSAT needs huge dish antenna.
- 3G can change the entire scenario but it will take time
for the technology to be established and accepted as a
standard.
- Mind set of people towards the upcoming technologies is a key factor.

17. Home Care at Manipal Hospital, Banglore
- patient calls Home Care HelpLine
- the logistics manager fixes up an
appoinment,
- trained nurses are despatched along
with fully equipped mobile van
- the centre is in touch with all its
nurses and vehicles using mobile
phones and GPS
- the nurse provides the care to the
patient
- if required, a consultation with the
doctor is made by store & fwd Telemedicine using the Laptops

18. Telemedicne: Patient’s perscective
Mrs Lathika (Patient, Apollo Hospital)
Mr. Jagdeesh (Patient, Apollo hospitals)
Mrs Lathika is from Chennai, she has recently moved to Bangalore.
Her doctor is in Apollo Chennai. She is very happy that she can consult
with her own doctor who is in Chennai through Telemedicine because he
has been treating her for a long time and knows her case well. She is able
to save time and effort of making a journey to Chennai.
Jagdeesh is a middle aged government employee. He
was not aware of the telemedicine techniques and practices. He
has good knowledge of technologies such as
Internet and computing systems as he is using it for official
purpose. When we introduced the telemedicine concept, he was
amazed because he can reduce travelling expenses and time.
That day he had taken leave for one day and came to hospital for
consultation. We understood that he represents a major population of patients.
Ms. Prasanna (Patient, Apollo hospitals)
Ms. Prasanna is a mid-aged housewife. She also shared her travelling problem for taking consultation. But one of her relative is a doctor.
Whenever a medical problem arrives, Prasanna used to call this relative,
tells the symptoms and asks for opinion. Most of the times, it works
perfectly alright and Prasanna is very much comfortable with this
telephonic consultation.
Mr. Raghav Raj
Raghav is a softaware engineer. He took leave for a day and came for
consultation. He was very irritated with the problems such as traffic
blocks, queue in hospitals, in-efficiency of the system etc. He actually gave
some insights about the advancements happened in developed countries
such as remote surgery, advanced sensors and applications. When we
proposed the telemedicine system for home care, he was happy and he
told that its impact will be more in urban areas where time and good
health are the main luxuries of people.
Mr. Roy (Patient, Apollo hospitals)
This patient was aged more than 55 and he shared his
difficulties in getting consultation. His son is working in a private
firm and took one day leave for taking his father to hospital. So
he is feeling like he is becoming a disturbance. When we asked
about the possibility of getting consultation through Internet,
sitting at home, he was very happy. He said that his grandson is
aware of Internet and he will help him in getting consultation.
They already have all facilities such as computer, web cam, mic
and Internet connection at home.

19. Telemedicne implementation by Neurosynaptics Communications
The telemedicine available in India are in the secondary and tertiary level i.e.
hospital-to-hospital as well as consultation with a super- specialist. Here there is no
direct involvement of patient i.e., a patient can be connected only through a doctor
to the telemedicine network. In India doctor to patient ratio is very low especially in
rural areas where 70% of the Indian population resides. The telemedical setup
currently available in India is not accessible to the patients in rural areas. To start a
telemedicine center in rural area itself is a challenge to the medical society. The
technologies developed so far are complex and videoconferencing and all requires
high band width. Such facilities are not simply available and becomes unaffordable
in rural/remote areas. Also the maintenance cost is high.
Neurosynaptics is basically a company providing technology as well as service for
the telemedical setup. They concentrate on the primary level of telemedicine i.e.
directly connecting patients to the doctor from remote/rural areas
They developed a technology called ReMeDi (Remote Medical Diagnosis) in
collaboration with the TeNet group of IIT Madras using embedded software applications. This technology was patented and got recognized all over the world in the
field of telemedicine, and also won the Technology Pioneer a ward 2008 at the
World Economic Forum.
Salient features of the product:
Can measure 12 channel ECG, blood pressure, Chest and Lung sounds, and
temperature and pulse rate.
Includes complete video conferencing, which works on low bandwidth.
Support both real time and stored forward mechanism to transfer results of various
tests.
Complete patient medical record management system.
What makes it different?
It operates on low band width of 64 kbps. It can work even at 32 kbps.
It is battery operated (rechargeable), probes can be re-engineered, wireless connectivity with the PC and complete isolation of the patient from the AC mains.
Any non medical professional can operate with minimal training.
No medical data loss. I.e. accuracy.
Low cost with high quality.
Due to the above features, ReMeDi can be used to implement telemedicine in
rural/remote areas of India where there is very less medical and technical
professionals/infrastructure.
This technology is being utilized by an organization called World Health Partners
(WHP) in setting up a Telemedicine network in India. Its Central Medical Facility
is in Greater Kailas 2, Delhi, which connects 154 telemedicine centers in 3
districts of UP and 1 district in MP. Within 8 months they are working to set up a
total of 2000 centers all over the world.
The requirements with reference to their network set up in Delhi is given below.
Basic requirements of a telemedicine p-center are:
A 10 X 10 sq feet room, a PC, a webcam, mic and head phone, internet of 64
kbps, ReMeDi Medical Data Acquisition Unit (MDAU), furniture required , and an
operator with a minimal operational knowledge. They are using USO scheme of
BSNL, which is only for rural areas, providing cheap internet connectivity of Rs
250/month. The total cost for such a set up is between 1 and 1.5 lakh.
The requirement in the central medical facility (CMF) includes:
The CMF is expected to be built on an area of 20 X 30 Sq. feet with at least 5 X 5
sq. ft area for Server with AC arrangement. The CMF should have place to keep a
Hardware Server, a Table for it. It should have backup server and good UPS and
generator. Solar Power back is generally not preferred for CMF. There should be
arrangement of cubical for Doctors and assistants. Each of these Doctors and
assistants should be provided with desktop PC/ Laptops with proper headphone and microphone and an internet connectivity separately (or in the LAN)
of at least 128 Kbps Connections.

20. Working model of ReMeDi
CENTRAL MEDICAL FACILITY
The patient visits the telemedicine center. The operator enters the prime
details and connects to the CMF through internet. There is an operator at the
CMF who receives the information through the server. He transfers the information to the doctor depending on the requirement or the disease of the patient
through a LAN network. The patient can now directly talk with the doctor. The
ReMeDi Medical Data Acquisition Unit (MDAU) can be activated only by the
operator at the CMF or by the doctor. The required ports of the unit is activated
depending on the diagnosis required. The operator at the rural center uses the
probes and leads as per the doctor’s instruction. Either Real time, or stored-andforward data transmission of various tests takes place depending on the case.
The doctor diagnoses the disease and gives suggestions accordingly and
prescribes the medicine. Probably the center itself has a pharmaceutical or there
should be at least 1 pharmacy for every 2 centers depending on the distance
and all. If the patient is in serious condition immediately the ambulance service
is provided and he or she is been taken to the nearest hospital.
This technology can also be used in a shared platform which can further
reduce the cost of setting up a center. The services like DTP, photography,
e-governance, education, agriculture, veterinary care etc. also uses the basic
infrastructure like PC, webcam, microphone, speaker, printer etc. Thus the
equipments become fully occupied for the whole day if it is used in a shared
platform.
CENTRAL
SERVER
ASSISTANT
LAN NETWORK
D1
64 kbps
Data transfer
D2 D3 D4 . . . . .
DOCTORS
INTERNET CLOUD
64 kbps
Data transfer
Video
conferencing
Patient walks in.
RURAL HEALTH CENTRES
OPERATOR
PATIENT
ReMeDi kit & Probes.
This kit is able to measure ECG, BP, Temperature, Heart & lungs sounds.
This kit is there in each rural health centres. Can be only activated
by doctor or assistant in CMF. Kit is even active in 32 kbps.

21. Analysis
Telemedicine has a significantly increased on just the the reach
accessiblity of health care but also the quality of health care. It has made health
care available to the poorest of poor who would never have dreamt of getting a
consultation with the specialists. It saves a lot of time, effort and money involved
in travel for the patient.
Telemedicine used by some big Hospitals in Banglore : connects mostly
hospitals belong to the same chain. It its used for providing teleconsultations,
second openion, and telementoring. They donot yet provide telemedicine services to the rural areas.
There are also other hospitals like narayana hrudhyla which cater to the
masses- they provide telemedicine to the masses for free.
More such developments and innovations are required in this field. For this Telemedicine awareness must be created.
There are very few institutes that include Telemedicine as part of the
curriculum
SGPGIMS does a lot of active R&D on Telemedicine, acts as a hub of
telemedicine, is involved in a lot of events related to Telemedicne, and maintains
a good web presence. There is a dearth of Educational & Research Institutes
which are involved in Telemedicine.
The dedicated HealthSAT provided by ISRO is one of the major technological supports for Telemedicine, which has made this service affordable and accessible to the poor needy of the most remote areas of the Nation.
Technology:
Using existing technology itself to the full extent is sufficient to provide
basic Telemedicine. Better technology, greater bandwidth, Expertise in using the
technology is required for Providing State of the art Telemedicine service like
Robotic Surgery.
3G can greatly improve the existing telemedicine scenario by providing
much higher bandwidth required for video conferencing.
Lot of innovative and cost effective technologies are being adopted like
hrudayala post, TTECG, ReMeDi etc. Cisco, Seimens, GE etc have Connected
health programmes for providing telemedicine.
Issues (Scope for design intervention) :
• Technology has not reached most of the rural areas, many villages don’t
even have electricity- this becomes a barrier for implementing Telemedicine.
• Bandwidth and internet facility not good enough for high end telemedicine
• Inefficient utilization of existing technology
• There are interoperability issues between software.
• Misuse of telemedicine resources
• Maintenance issues of telemedicine centres lead to shutting down of the
centres.
• Political influences and issues
• Very little awareness about telemedicine facility and benefits
• There is no strict regulations and standards in telemedicine delivery. This
is necessary for the proper
• Financial support and incentives to start up & maintain centres in rural
areas.
• Many private hospitals are profit oriented and and donot have much
programs directed at the rural areas.
• Exisiting telemedicine sys concentrates mainly on Secondry and Tertiry
care, very little in primary care where a patient can directly get access to
the specialist.
• Telemedicine has good potential in Homecare but it is not being
explored currently.
• People have technofear- feeling that computers would make them
unemployed.
• And many people are not convinced that technology can effectively help
them.

22. Proposed Implementation Model
·
Vision: Improvement in
-
Accessibility,
Cost effectiveness,
Quality of care,
Patient safety,
Patient satisfaction.
·
Research: Identify the public health care needs.
·
·
Areas of requirement
Remote areas where the reach of medical facility is less,
Home scenario where patients finds difficult to travel,
Ambulance etc.
Funds and the implementation cost.
·
Standards, authorisation, legal issues and government support.
·
Whom to collaborate:
Hospitals (govt. ,pvt),
Pharmaceuticals,
Technology providers,
Government
Doctors,
Public etc.
Educational & Research institutes
·
Awareness among the public about
- The need of telemedicine
- The technologies & services provided
- Cost effectiveness and efficiency
- About the collaborations
·
Start central medical facilities and rural health centres
·
Invite local agencies to start telemedical centres.
·
Support with bank loans.
·
Provide primary operational training.
·
Provide full support and guarantee for a long period
Technical support, Maintenance,
·
Make sure that the centres functions properly
Misuse of the facilities may happen
Irresponsibility of the centre in charge
·
Get feedback and improve the facilities and services.
·
Introduce new technologies with time.
·
Extend the number of end users by starting more centres.
·
Active interaction between the stakeholders of the system.
·
A committee to settle the issues like
Political
Socio-economic
Issues between the stake holders of the system

23. Proposed Service Delivery Model -1
Telemedicine Deilvery Model for Post Surgery HomeCare
Patient to bed ratio in India
is very low
Patients need care
even after being
discharged
Limitation of
Enrty/Visitors to relatives
and well wishers into
hospitals
Recovery is best at
homecomfort and love
Need
Basic Telemedicne Equipments,
VedioConf Capability,
Sensors,
Interface Device (mobile phone)
Very High cost of
hospitaliztion
Limited number of Care
Givers comapred to
patients
Trained Professional/Nurse,
Mobile Van,
Support Doc at the Hospital
Requirements
Electricity
Telemedicine Deilvery
Model for Post Surgery
HomeCare
How
Communication Link:
Internet/ ISDN/ Satellite
in the Fig.
Manisha S

24. Telemedicine Deilvery Model for Post Surgery HomeCare
Manisha S

25. Proposed Service Delivery Model -2
This model focuses on elderly people and children.
There is a specially designed device contains some sensing mechanism which continuously listens to changes happening in the
patients body. This device is very small and wearable so that the
patient wont mind carrying it full time. We can programme the
device in such a way that it sends real time medical information of
the patient to the nearest hospital. Inside the hospital, they have a
listening system which displays the real time status of each and
every patient.
There will be some normal values set inside this device. Real time
values from the patients body is compared with these normal values
and when ever it crosses the limit value, the system will perform
three actions simultaneously.
Sends an ALERT message to the nearest hospital.
Sends an ALERT signal to the Ambulance service with the patients
current location.
Calls one emergency number and conveys the message.
There is hardly any technology hurdles for implementing this
project. The major part of the design is the multi-sensor device. The
accuracy of the device is also a matter of concern.

26. Conclusion
Telemedicine seems to be the cheapest way to bridge the urban- rural divide in access to health
care in India. Telemedicine has been successfully inplemented in many villages in India, but it is
only the tip of the ice berg. India being a Hub of IT, there is very good scope for further growth
of telemedicine, with support of greater technology, standardization and regulations.
Making tele-healthcare more accessible is possible only by the active involvement of all stakeholders Government, hospitals, Technology providers, Support staff, Educational & Research
Institutes, Insurance, Financiers and Patients.

27. Acknowledgements
We thank Mr. Abhay Singavi, CEO Preventive Health, Narayana Hrudhyala, for spending time with us and giving us solid ground to work on. We thank Rajen Padukone,
CEO Manipal Hospitals for arranging a meeting for us. We also thank Khemchandra Birhade ( Vice-President, Business Development ) NeuroSynaptics for sharing their
work process, expertise and experiences with us. We thank Mr Nandhkishore Dhomne, CIO, Manipal Hospitals, Mr. Praveen & Mr Joshy, Technical Dept , Appolo hospitals,
Sister Greta & Ms Shiney, Home Care, Manipal Hospitals, and all other patients for spending time and sharing thier experience with us.
A huge thanks to Dr. Baral, Research Head, NID R & D Campus for inititating us into this project. His guidance, insights and 24x7 support was Invaluable to our research.
We also thank Pradeep, KMC assistant for helping us with get articles.
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