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Telehealth Report - India
International Telemedicine Congress - 2011 
Foreword 1 
Editorial 2 
Executive Summary 4 
Telemedicon 2011 5 
Telemedicine Concept 6 
Telemedicine in India 17 
Initiatives 32 
Opportunities and Challenges 45 
Industry Speaks 53 
Business Models 58 
Learning and Resources 60 
Continua Health Alliance 65 
Roadmap Ahead 67 
References 71 
Telehealth Report - 2011 
with proceedings of 
Contents
Rajendra Pratap Gupta 
International Healthcare Expert & 
Chairman, Organizing Committee 
International Telemedicine Congress – Telemedicon’11 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
1Foreword 
India is presently building on its healthcare system, and the 12th Five Year Plan has been referred to as 
the ‘Plan for Health’ ! Now is the right time for the policy makers to ensure that technology is embedded 
in all programs that the Government is planning to rollout for healthcare delivery. In specific, mHealth 
has tremendous potential to reduce costs, improve the reach and access to healthcare, make the 
healthcare system more outcome driven, and more importantly, help in establishing an ‘empowered 
patient’. 
With approximately 900+ million cell phones, healthcare in India will converge to mHealth, and 
ultimately, this is where all practitioners, payers and users will converge too! It is time to look at 
mHealth as a tool for ‘Inclusive Healthcare’ . Without mHealth,‘Universal Healthcare’ will just remain a 
dream ! 
Being personally involved in many mHealth & Telemedicine ventures and policy initiatives, I have 
always felt that when it comes to Telemedicine & mHealth, there is no concrete report that can fill in the 
readers with the detailed and up-to-date information, and so this attempt to come out with the first 
‘Telehealth Report’- 2011. We have done our best to ensure that the report is accurate and full of facts 
from the users, policy makers and industry point of view. Still, this report could have inadvertent errors 
or short comings, as it usually happens with the so called ‘First Timers’. Please feel free to write back for 
any suggestions you might have . 
I do hope that this report will be of immense help to users, providers and policy makers for mhealth & 
eHealth - not just in India, but across the world . I do look forward to your comments & feed back. 
Yours in good health 
Member, Healthcare, Quality Council of India 
President, Disease Management Association of India 
Chairman, Board of Directors, HIMSS Asia Pacific India Chapter 
Co-Chair, Sub-Group on Chronic Diseases, Confederation of Indian Industry 
Member, Governing Council, Telemedicine Society of India 
Member, Board of Directors, Care Continuum Alliance, Washington, USA 
Email : chairman@telemedicinecongress.com 
www.telemedicinecongress.com
Dr. Sam Pitroda 
Advisor to the Prime Minister of India 
on Public Information and Innovations 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
2 Editorial 
Technological advancements have come a long way from the time of the great Industrial Revolution. 
What was initially feared for its negative consequences on society has emerged to be the culture of 
‘Technological Utopianism’. Whether the technology boom can actually help realise this utopian 
environment or not, it sure has come to address many major issues across industries. 
Industrialization has been marked by the coming together of two advancements, telecommunication 
and Information Technology, for bridging the technology gap between developed and the developing 
world. These powerhouses of global economy have been greatly accepted into the healthcare industry 
to aid in cure delivery, while paralleling the dynamic achievements made in medical sciences. As a form 
of Information and Communication Technologies (ICT), Telemedicine and mobile health are being 
largely employed across the globe to bridge the urban rural disparity in receiving care services. 
Telemedicine is best suited for nations like Africa and India, which have large populations in rural areas, 
devoid of quality care services and separated by great distances. Yet the adoption of these technologies 
is in its infancy. The industry as a whole needs to take the next step forward from the numerous pilot 
programs now underway to finding means of encouraging widespread roll out of Telemedicine and 
mHealth. The increasing use of internet and mobile phones across the globe, two of the basic 
requirements of Telemedicine, provides the industry ample impetus to advance this approach of care 
to a higher level. Improvements and advancements in telecommunication infrastructure and 
technology, the advent of high speed internet, improved connectivity, increased computer literacy and 
reduction in telecom service cost will further drive the industry. Furthermore, better privacy and 
security of confidential patient data and standardization of regulatory policies will form the pillars to 
remote provision of care services. 
With so much interest being induced in this emerging area of healthcare, hopefully Telemedicine will 
transform itself into a self-sustaining economic environment. This congress, featuring the pioneers and 
innovators in the field of Telemedicine, was a platform for ideas and experiences to open into 
opportunities for immense growth and development in this area of healthcare that has already shown 
great potential and promise. I would like to congratulate Rajendra Pratap Gupta from the Telemedicine 
Society of India for organizing an event of this magnitude and coming out with India’s First Telehealth 
Report
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
3Disclaimer 
Telemedicine Society of India has exercised professional care and diligence in collection and processing 
of the information in this report. 
However, the data used in the preparation of this report (and on which the report is based) was 
provided by third-party sources. This report is intended to be of general interest only and does not 
constitute professional advice. 
Telemedicine Society of India makes no representations or warranties about the accuracy of the data in 
this report. Telemedicine Society of India is not liable to any user of this report or to any other person or 
entity for any inaccuracy of information contained in this report or for any errors or omissions in its 
content, regardless of the cause of such inaccuracy, error or omission. The quotations/views expressed 
in this report are those of the Industry leaders/speakers and do not necessarily represent views of 
Telemedicine Society of India. 
Furthermore, to the extent permitted by law, Telemedicine Society of India, its members, employees 
and agents accept no liability and disclaim all responsibility for the consequences of you or anyone else 
acting, or refraining from acting, in relying upon the information contained in this report or for any 
decision based on it, or for any consequential, special, incidental or punitive damages to any person or 
entity for any matter relating to this report even if advised of the possibility of such damages. 
© Telemedicine Society of India . 
Please do not copy or reproduce in 
whole or part thereof, the contents of 
this report without the written permission 
from chairman@telemedicinecongress.com 
For additional copies , please write to 
chairman@telemedicinecongress.com
4 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Executive Summary 
Despite a steady increase in the number of medical establishments and improvement in India’s 
healthcare infrastructure, much remains to be accomplished. There still remains a severe shortage of 
sub centres, primary health centres, and community health centres. While Telemedicine offers great 
opportunities in general, it could be even more beneficial for underserved and developing countries 
like India, where access to basic care is of primary concern. One of the biggest opportunities 
Telemedicine presents is increased access to health care. Providing populations in these underserved 
countries with the means to access health care has the potential to help meet previously unmet needs 
and positively impact health services. 
Telemedicine applications have successfully improved the quality and accessibility to medical care by 
allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically 
developed countries. They can provide efficient means for accessing tertiary care advice 
in underserved areas. By increasing the accessibility of medical care, Telemedicine can enable patients 
to seek treatment earlier and adhere better to their prescribed treatments, and improve the quality of 
life for patients with chronic conditions. 
Indian Telemedicine has come a long way since India's first Telemedicine centre at Apollo Aragonda 
Hospital was inaugurated in 2000. With its large medical and IT manpower and expertise in these areas, 
India holds great promise and has emerged as a leader in the field of Telemedicine. Key growth drivers 
include low cost of Telemedicine and wide reach over satellite or fiber optic bandwidth, lack of 
healthcare facilities in far-off regions, reduced technology cost and availability of qualified technical 
personnel, shortage of qualified medical professionals, and growth of ICT as a sector 
Although there are many factors that are encouraging the adoption of Telemedicine as a medium of 
healthcare service, there are few challenges as well faced by the industry. Issues such as absence of 
global regulatory framework, lack of basic IT infrastructure, reimbursement policies, and legal 
constraints hinder the growth of the Telemedicine market. Lack of common standards and 
classification could pose a challenge to the growth of this market.
5 
Telemedicon 2011 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Telemedicine Society of India organized the 7th International Telemedicine Congress, Telemedicon’11 
from 11-13th November at Hotel Westin in Mumbai. 
Telemedicon’11 was the ‘Biggest Healthcare Congress that has ever happened in India’. The event had 
an overwhelming response from one and all, which can be judged from the fact that all the exhibitor 
space was sold out weeks before the congress. The organizing committee members had to stop the 
registration process few days before the congress. Over 500 delegates from over 20 countries 
participated in the Telemedicine congress event held at Hotel Westin, Mumbai in India. Distinguished 
guests/speakers like Mr. Aneesh Chopra, CTO and Assistant to the President of USA; Shri Sachin Pilot, 
Hon’ble Minster of State for IT, Government of India; Dr. Prathap Reddy, Chairman, Apollo Hospitals 
Group; Shri Shankar Aggarwal, Additional Secretary, DIT, Government of India; Lord Nigel Crisp, Dr. 
Dale Alverson and a host of global healthcare leaders made this event a memorable one, and one of the 
biggest and most successful events in the Healthcare Industry. The entire Telemedicine ecosystem 
(telecom operators, telecom equipment manufacturers, mobile handset manufacturers, software 
vendors, policy makers, healthcare professionals) was present under one roof. 
Telemedicon’11 has become an iconic conference in many ways as it has also launched the Continua 
Health Alliance on 13thNovember 2011, followed by an interoperability workshop, for the first time in 
India. About 40 Exhibition stalls were organized by the top players in Telemedicine to demonstrate their 
products/services.
Telehealth Report - 2011 
In the current environment of Ÿ shortage of healthcare professionals and greater incidence of chronic 
conditions, and rising healthcare costs, are driving the need to develop tools and solutions to 
improve healthcare delivery. One such tool is the electronic exchange of medical information, which 
is commonly referred to as Health Information Technology (“Health IT”). Health IT plays a key role in 
digitizing and transmitting health information electronically that can improve patient outcomes. 
Health IT processes can also include: 
ŸUse of electronic health records by patients, physicians, insurers, hospitals and clinics 
ŸHealth information exchange across industries and geographies 
ŸUse of electronic health information to detect trends in population and public 
health 
ŸTransmission of medication refills and a patient’s prescription history. 
A key part of Health IT is increasing the frequency and use of technology-driven remote monitoring and 
consultation to treat patients. This area of Health IT is commonly referred to as “Telemedicine.” There 
is no universally accepted definition of Telemedicine.However, the American Telemedicine Association 
(ATA) defines the term as follows : 
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Telemedicine Concept 
with proceedings of 
International Telemedicine Congress - 2011 
What is Telemedicine? 
“Telemedicine is the use of medical information 
exchanged from one site to another via electronic 
communications to improve patients’ health status” 
It is a broad term within Health Information Technology that encompasses methods for electronically 
transmitting medical information. These methods can include store-and-forward technology for 
documents and images, remote monitoring of a patient’s vital signs, secure messaging, e-mail 
exchange of data, alerts and reminders between physicians and patients, and the ability to observe, 
diagnose and recommend treatment via videoconference. Telemedicine can eliminate distance 
barriers and can improve access to medical services that would often not be consistently available in 
distant rural communities. 
Closely associated with Telemedicine is the term ‘telehealth,’ with the former restricted to service 
delivery by physicians only, and the latter signifying services provided by health professionals in general, 
(including nurses, pharmacists, and others). Videoconferencing, transmission of still images, e-health 
including patient portals, remote monitoring of vital signs, continuing medical education and nursing 
call centers are all considered part of Telemedicine. 
Major areas of Telemedicine include Teleradiology, Teleconsulting, Telemonitoring, & Telesurgery 
Ÿ Teleradiology, is the transmission of radiological patient images, such as x-rays, CTs, 
and MRIs, from one location to another, for the purposes of sharing studies with other radiologists 
and physicians. Teleradiology is a growth technology given that imaging procedures are growing 
approximately 15% annually against an increase of only 2% in the Radiologist population 
Ÿ Teleconsulting, is using Telemedicine for medical consultation. 
Ÿ Telemonitoring, can be defined as the use of information technology to monitor patients at a 
distance. 
Ÿ Telesurgery, (also known as remote surgery) is the capability for a doctor to perform surgery on a 
patient even though they are not physically in the same location. It is a form of telepresence.
Telehealth Report - 2011 
mHealth 
mHealth is a new area emerging within the field of Telemedicine. mHealth or 
mobile health is a term used in reference to using mobile communication 
devices, such as mobile phones and PDAs, for health services and information. 
Nigel Crisp, Former CEO of NHS & Member, House of Lords 
mHealth applications include the use of mobile devices in collecting community and clinical health data, 
delivery of healthcare information to practitioners, researchers, and patients, real-time monitoring of 
patient vital signs and direct provision of care. 
Products and Service Offerings 
There are multiple industries that are involved in developing various applications of Telemedicine, 
including IT vendors, medical device manufacturers, pharmacies, hospitals, nursing homes, and 
venture capitalists. Accordingly, there are numerous products and services comprising Telemedicine. 
Products : Many medical devices capable of collecting and electronically transmitting information can 
be digitized to be used in Telemedicine applications. These include blood gluc ose meters, pulse 
oximeters, blood pressure cuffs, spirometers, CT scanners, and MRI machines. Some of these devices 
are targeted towards home healthcare and the needs of patients interested in closely monitoring their 
health status, while others facilitate the exchange of information between hospitals, clinics and 
physicians. 
Services : The use of medical products with electronic exchange capabilities allows for the provision of a 
wide range of Telemedicine-related services. These include st ore-and-forward technology for 
documents and images, remote monitoring of a patient’s vital signs, secure messaging, e-mail 
exchange of data, alerts and reminders between physicians and patients, and having a specialist 
remotely available by videoconference to observe and diagnose a patient’s condition and recommend 
treatment. Electronic exchange of prescription information between physicians, pharmacies and 
consumers is an additional service. Other Telemedicine services include transmitting information to 
alert communities about pandemics, and other widespread health threats. 
Evolution of Telemedicine 
Due to the recent advances in ICT, interest in Telemedicine has increased in the last few years. The 
concept is not new. The first reference of the subject is probably the famous “Radio Doctor” cover 
image of the 1924 Radion News Magazine. One of the first Telemedicine applications reported in 
the scientific literature was the project for transmission of radiologic images by telephone 
between West Chester and Philadelphia, Pennsylvania, covering a distance of 24 miles. 
NASA used Telemedicine in the 1960s as a way to monitor astronaut health on space missions. 
Today, it’s used to electronically exchange medical information among patients, clients and health 
providers, creating greater access to medical evaluation and improving patient care. 
In the 1970s, the number of Telemedicine projects started to grow and the first real-time applications 
were mentioned. The STARPAHC Project tried to introduce Telemedicine in the rural Papago Indian 
Reservation in Arizona. Throughout the 1980s, Telemedicine specialty specific applications started to 
emerge, for example telepathology, which was first mentioned in 1986. The field of radiology saw the 
7 
“In UK, National Health Service (NHS) Direct started free 
health advice service over telephone. It has over six million 
subscribers, over 10% of the Country’s population.” 
Telemedicine Concept 
with proceedings of 
International Telemedicine Congress - 2011 
Health IT 
Telemedicine 
mHealth 
Chart 1: Health IT vs. 
Telemedicine vs. mHealth
8 
development of the first standard on digital 
medical imaging which culminated in the release 
of the DICOM specifications in 1992. 
The number of Telemedicine applications started 
to grow rapidly in the 1990s due to the availability 
of internet, affordable computers and digital 
imaging solution. The lat est technical 
breakthrough in Telemedicine was probably the 
first transatlantic robotic operation which was 
performed in 2001 by a surgeon in New York on a 
patient in Strasbourg. 
At present, electronic medical data, such as high 
resolution images and live video, are transferred 
through a v ariety of t elecommunication 
technologies, from fiber optics and satellites, to a 
simple telephone line. A growing number of 
medical specialties rely on Telemedicine to serve 
patients in areas such as adult rehabilitation, 
dermatology, emergency services, home 
healthcare, nephrology, pathology, paediatrics, 
perinatology, primary care, psychiatry, and 
radiology. 
Current Deployment Scenario 
In 2010, World Health Organization (WHO) 
conducted a survey to obtain an impression of the 
current state of Telemedicine service provision as 
well as four of the most popular and established 
areas of Telemedicine. 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), ‘informal’ 
(services not part of an organized program) or ‘no 
stage provided’ (services not part of any platform). 
The survey examined four fields of Telemedicine : 
1.Tele -radiology: 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. 
2.Tele-pathology: Use of ICT to transmit digitized 
pathological results (e.g. microscopic images of 
cells) for the purpose of interpretation and/or 
consultation 
Telemedicine Concept 
Telemedicine 
The idea of performing medical examinations 
and evaluations through the 
telecommunication network is not new. 
Shortly after the invention of the telephone, 
attempts were made to transmit heart and 
lung sounds to a trained expert who could 
assess the state of the organs. However, poor 
transmission systems made the attempts a 
failure. 
Ÿ1906 ECG Transmission: Einthoven, the 
father of electrocardiography, first 
investigated on ECG transmission over 
telephone lines in 1906 
Ÿ1920s 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 
Ÿ1924 The first exposition of Telecare: 
Perhaps it was the cover of "Radio News" 
magazine of April 1924. The article even 
includes a spoof electronic circuit diagram 
which combined all the gadgets of the day 
into this latest marvel 
Ÿ1955 Telepsychiatry: The Nebraska 
Psychiatric Institute was one of the first 
facilities in the country to have closed-circuit 
television in 1955. In 1971, the 
Nebraska Medical Centre was linked with 
the Omaha Veterans Administration 
Hospital and VA facilities in two other 
towns 
Ÿ1967 Massachussetts 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 
travellers 
Ÿ1970s 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 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011
Telehealth Report - 2011 
International Telemedicine Congress - 2011 
Telemedicine Concept 
with proceedings of 
3.Tele-dermatology: Use of ICT to transmit medical information concerning skin conditions (e.g. 
tumours of skin) for the purpose of interpretation and/ or consultation. 
4.Tele-psychiatry: Use of ICT for psychiatric evaluations and / or consultation via video and telephone. 
Table 1: Teleradiology – Most developed 
Service areas in Telemedicine Established Pilot Informal No Stage Provided Total 
Teleradiology 33% 20% 7% 2% 62% 
Telepathology 17% 11% 9% 4% 41% 
Teledermatology 16% 12% 7% 3% 38% 
Telepsychiatry 13% 5% 5% 1% 24% 
Tele-radiology is currently the most developed Telemedicine service area globally, with 62% of 
responding countries offering some form of service and 33% of countries having an established service 
(Table 1). While the proportion of countries with any form of service ranged from almost 41% for 
teledermatology and telepathology, to 24% for telepsychiatry, the proportion of countries with 
established services in those three areas was comparable at approximately 15%. 
“Telemedicine has done well, but the difference is not visible to the 
audience. In order to make the difference visible, we need to bring 
examples of real health and economic benefits that Telemedicine 
provides” 
Nigel Crisp 
Former CEO of NHS and Member, House of Lords 
Telemedicine in developing countries 
While Telemedicine offers great opportunities in general, it could be even more beneficial for 
underserved and developing countries where access to basic care is of primary concern. One of the 
biggest opportunities Telemedicine presents is increased access to health care. Providing populations 
in these underserved countries with the means to access health care has the potential to help meet 
previously unmet needs and positively impact health services. 
Telemedicine applications have successfully improved the quality, and accessibility to medical care by 
allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically 
developed countries. They can provide efficient means for accessing tertiary care advice 
in underserved areas. By increasing the accessibility of medical care, Telemedicine can enable patients 
to seek treatment earlier and adhere better to their prescribed treatments, and improve the quality of 
life for patients with chronic conditions. 
Telemedicine has been advocated in situations wherein the health professional on duty has little or no 
access to expert help, with need to offer remote physician access to otherwise unavailable specialist 
opinions, thereby providing reassurance to both doctors and patients. Telemedicine programs have 
been shown to directly and indirectly decrease the number of referrals to off-site facilities and reduce 
the need for patient transfers. Remote care and diagnosis via Telemedicine in less-economically 
developed countries thus benefits both patients and the health care system by reducing the distance 
travelled for specialist care and the related expenses, time, and stress. Furthermore, Telemedicine 
programs have the potential to motivate rural practitioners to remain in rural practice through 
augmentation of professional support and opportunities for continuing professional development. 
9
Telehealth Report - 2011 
With progress in technology, the expansion of Telemedicine in developing countries is promising, one 
factor being the falling costs of ICTs. Other factors include increasing computing speeds, options for 
high-speed bandwidth and the falling costs of digital storage. Already basic store-and-forward e-mail-based 
Telemedicine requires minimal investment in hardware and software where network 
connectivity is available, and allows for detailed exchanges by enabling the transfer of images as 
attachments, making it an effective solution for low-resource settings. The growing development of 
Internet-based conferencing (particularly through no-cost software) increases the accessibility and 
portability of conferencing and counters the need for expensive video conferencing equipment that 
may be limited by availability. Low bandwidth, Internet-based Telemedicine (e.g., store and forward, e-mail- 
based consultations) has also proven to be a cost-effective technology that can efficiently and 
effectively pre-screen patients living in remote areas. By enhancing the information communication 
technology infrastructure and developing better communication facilities, Telemedicine can also add 
to the better management of scarce medical resources and day-to-day activities in the developing 
world. 
What is holding Telemedicine in developing countries? 
Barriers in realizing true potential 
Infrastructure in developing countries is largely insufficient to utilize the most current Internet 
technologies. This lack and inadequate access to computing are barriers to Telemedicine uptake for 
many developing countries. At the most fundamental level, the variability of electric power supplies, 
widespread unavailability of internet connectivity beyond large cities, and information and 
communication equipment that is not suitable for tropical climates impose limitations on where 
Telemedicine can be implemented. Unreliable connectivity, computer viruses, and limited bandwidth 
continue to present challenges when and where Internet access is available. Internet congestion can 
lead to delayed imaging; poor image resolution may limit the efficacy of remote diagnosis; and slow 
bandwidth can prohibit the use of real-time videoconferencing. Even when basic infrastructure is in 
place, widespread interoperability standards for software are lacking and equipment or computer 
system failure remains an ever-present possibility. 
Financial cost also poses both a real and perceived barrier to the application and adoption of 
Telemedicine in developing countries. Equipment, transport, maintenance, and training costs of local 
staff can be daunting for countries with little income or limited funding for the implementation and 
maintenance of Telemedicine initiatives. Moreover, convincing evidence to support the overall cost-effectiveness 
of particular Telemedicine strategies may be weak, while the economic implications of 
such strategies in different settings may not yet be known. 
Local skills, knowledge, and resources may also limit the application of Telemedicine in developing 
countries. A lack of computer literate workers with expertise in managing computer services, combined 
with the lengthy process required to master computer-based peripheral medical instruments, can 
hinder uptake. While there may be a demand for distance learning, meeting local educational needs 
can be difficult due to differences in the diagnostic and therapeutic resources available, as well as the 
literacy and language skills across multiple sites. Moreover, while Telemedicine may enhance expert 
diagnosis, treatment options available are constrained by logistical challenges, including the training of 
local medical personnel, availability of medical equipment and supplies, and getting medicines to 
patients. 
Socio-cultural differences between sites can limit the pertinence of Telemedicine collaborations in the 
developing world and challenge cultural perspectives related to health and wellness. A major 
contributing factor to Telemedicine failure is the oversight of incompatible cultural subsystems that 
prevent the transfer of knowledge from one cultural context to another. Medical professionals in the 
industrialized world may be unfamiliar with the available facilities and alternative management 
strategies in remote areas and vice versa. Telemedicine, therefore, risks the exchange of inappropriate 
or inadequate medical information. Without a good understanding of the local context, it may be 
difficult to integrate Telemedicine in a useful way. 
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International Telemedicine Congress - 2011 
Lack of information available regarding legal policies, guidelines, or minimum standards concerning 
the use of Telemedicine in the clinical context can also prevent the adoption of such technologies. 
Cross-border legalities are a concern for developing countries that use Telemedicine services to 
connect with health professionals from more than one country. An overall lack of evaluation data, trials, 
and published results concerning Telemedicine initiatives in developing countries has limited the 
amount of evidence on the impact and effectiveness of Telemedicine. 
Complete evaluation is vital to systematically document best practices and lessons learnt from country-specific 
Telemedicine networks. Such evaluations will show which networks demonstrably alter health 
outcomes, prove to be cost-effective and are sustainable. These can then provide a model for other 
countries to adapt in their own contexts. Critical success factors include; clear program goals, garnering 
government and institutional support, adapting existing user-friendly interfaces, determining 
accessibility and connectivity constraints, implementing standards and protocols, and disseminating 
evaluation findings. 
Where can Telemedicine help? 
Application 
The healthcare-at-a-distance concept has been adopted to overcome distance barriers and improve 
access to healthcare services. Telemedicine is being applied to enable: 
Remote consultation: With Telemedicine, rural areas benefit from the same specialized services 
availed in urban areas. With the help of telecommunication and the internet, the technology has also 
been used to deliver care services to workers at oil rigs, passengers on board public transport, patients 
in transit, for medical tourism, and correctional systems. 
Home care: This application of Telemedicine has been driven by the rise in chronic conditions, aging 
populations, scarcity of hospital streambeds, and the current global focus of empowering patients with 
their own health. In support of Telemedicine technology, the delivery of care has evolved to include 
connected care; a care model that exploits the use of technology to provide healthcare remotely. 
Telemedicine is between provider and recipient, and forms a medium by which information is 
transmitted. This is facilitated by two basic approaches that are applied in various scenarios: 
1. Real Time (synchronous), when the exchange of information is immediate, and both the provider 
and recipient are present simultaneously at each of their ends. An example of the synchronous 
type is the usage of video conferencing for Telemedicine application. 
2. Store and Forward (asynchronous), where the information is acquired and stored in a particular 
format before it is sent for expert consultation, as in the case of using e-mail for exchange of 
information. 
The clinical applications of Telemedicine can also be categorized according to the different levels of 
technology maturity. 
Mature: The most mature applications of Telemedicine are in the areas of teleradiology and 
telepathology. The primary reason for these disciplines of medicine to adopt Telemedicine is the 
similarity between the two. It is a known fact that radiologists and pathologists rely extensively on 
imaging technology rather than direct contact to diagnose a condition. Hence, the practice of 
diagnoses through Telemedicine would not substantially differ from conventional mode. This is one of 
the most prominent reasons as to why radiologists and pathologists were the earliest adopters of this 
technology. 
Maturing: Maturing applications include telepsychiatry, teledermatology, telecardiology and 
teleophthalamology. Although there has been significant research interest in these areas, they are yet 
to receive institutional and professional acceptance globally, as there is a need for technology 
development, testing and dissemination, clinical guidelines and standards. 
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Emerging: The emerging applications have been telesurgery, telepediatrics and emergency medicine. 
Telesurgery has been making steady progress in the areas of remote surgery and teleconsultatative 
processes in view of advancements made in robotics and related technologies, as well as broadband. 
This arm of Telemedicine has been researched for telemonitoring (surgical instructions), and 
teleproctoring (overseeing a surgical procedure). Majority of research and the development in 
telepediatrics is focused on treating children with chronic illness and special needs. School based 
telepediatric services for underprivileged children is another area that has shown potential for 
mainstream application. 
How can Telemedicine help? 
Rationale 
There are several benefits that can be realized by an increased use of Telemedicine as also there are 
multiple factors driving the need for Telemedicine. Benefits can range from increased compliance in 
taking medications, to improved healthcare delivery in rural and underserved areas, to improved 
delivery of healthcare services outside hospitals and clinics, and better utilization of healthcare 
professionals. 
Manage chronic diseases effectively: Chronic conditions such as diabetes, congestive heart failure, 
and obstructive pulmonary disease, require long-term treatment and use of multiple specialists, all of 
which significantly increase costs. Widespread Telemedicine adoption allows vital sign information 
and monitoring to be gathered frequently (instead of only during periodic physician visits). Messages 
can then be simultaneously transmitted to the treatment team, allowing for possible early intervention 
(a physician or hospital visit) if a patient’s condition deteriorates. 
Extend reach to underserved/rural communities: Many regions of the world (both urban and rural) do 
not have a full range of healthcare services available. The presence of Telemedicine services in rural 
areas has been shown to improve care by decreasing transportation costs, more efficiently deploying 
healthcare professionals and specialists, and offering timely healthcare delivery without the obstacles 
presented by lakes, forests and mountains. 
Address shortages of healthcare professionals: Telemedicine services such as videoconferencing and 
remote consultations, better utilize current staff, whether at a hospital, physician’s office, or via home-care. 
The availability of Telemedicine technologies and procedures can also allevia te potential 
shortages of healthcare professionals by enabling remote consultations by physicians and nurses for 
patients located in other states or countries. 
Improve competitiveness of industry by controlling healthcare costs: With rising healthcare costs, 
Telemedicine can provide a tool for companies and insurers to better control and manage healthcare 
spending by enabling greater use of remote monitoring of a patient’s condition to minimize the need 
for acute care intervention, and more efficient deployment of healthcare professionals. 
Empower patients regarding their own health: Raising the responsibility level of patients to take their 
medicines and report basic health metrics to their physician by using Telemedicine represents an 
opportunity for patients and caregivers to play a greater role in their own care. 
Improve care of elderly, home-bound, and physically challenged patients: Use of Telemedicine to 
reduce the frequency of visits to physician offices and hospital emergency rooms can potentially lead to 
greater convenience and compliance for elderly and home-based patients. 
Improve community and population health: Electronic sharing of image s and video consults, a 
component of Telemedicine, permits easier exchange of information between public health services 
about a rare or unusual health condition, better measure chronic diseases in a population, or address a 
public health crisis. 
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Reduce deaths, injuries, and infections: Increased use of Telemedicine across all settings could reduce 
the incidence of adverse events caused by treatment and medication errors arising from piece-meal or 
inaccurate patient information, leading to more consistent patient treatment by limiting the number of 
hospital visits and reducing exposure to illness from other patients. In addition, electronic prescribing 
can help reduce errors in dispensing medicines by eliminating the need to decipher handwritten 
prescriptions. 
Global Telemedicine market 
The global Telemedicine industry has been growing remarkably and expanding virtually across all the 
medical areas for the past few years. The global market for Telemedicine was valued at USD 9.8 billion in 
2010, and it is expected to grow at a CAGR of 18.6% to reach USD 23 billion by 2015. 
The global telehospitals/clinics market in 2009 was USD 5.6 billion and accounted for approximately 
71% of the total Telemedicine market. This sector is valued at USD 6.9 billion in 2010 and is expected to 
reach USD 15 billion in 2015, at a CAGR of 16.8%. 
The telehome mark et, which 
represented approximately 29% of 
the Telemedicine market in 2009, is 
expected to contribute 34.7% by 
2015. This segment was valued at 
nearly USD 2.9 billion in 2010 and is 
expected to reach USD 7.9 billion in 
2015 at a CAGR of 22.5%. 
One of the key factors contributing 
to this market growth is federal 
grants offered in the USA. The 
global Telemedicine market has 
also been witnessing an increase in 
strategic partnerships. Healthcare 
o rga n i zat i o n s a re a d o p t i n g 
Telemedicine technologies to cater to the demand for healthcare services. Other key growth drivers 
include shortage of health professionals, ageing population, availability of application service provider 
model, and affordable broadband internet access. 
Growth prospects of the Telemedicine market vary according to geographies. USA and Europe 
dominate the world Telemedicine market. USA has witnessed deployment of numerous federal grants 
during the past few years, which has aided in the excessive growth of the Telemedicine market in the 
country. Europe, on the other hand, has been witnessing a strong demand for Telemedicine products 
due to the rise in aging population and enhanced requirements for home treatments. 
Asia is the fastest growing region. It exhibits huge growth potential in the coming years as Telemedicine 
demand in this region will be driven by rising healthcare costs. There is a substantial rise in demand for 
Telemedicine in China and India. As governments and private players have stepped into the industry 
across most of the geographical locations, the future prospects of the market show immense 
opportunities to tap into. 
Although there are many factors that are encouraging, the adoption of Telemedicine as a medium of 
healthcare service, there are few challenges as well faced by the industry. Issues such as absence of 
global regulatory framework, lack of basic IT infrastructure, reimbursement policies, and legal 
constraints hinder the growth of the Telemedicine market. Lack of common standards and 
classification could pose a challenge to the growth of this market. 
Telemedicine Concept 
CAGR 18.6% 
(2010-2015 ) 
$Bn 
25 
20 
15 
10 
5 
2009 A 2010 A 2015 E 
Telehospitals / clinics Telehome 
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As Telemedicine has the potential to improve both the quality and the access to health care regardless 
of the geography; the rural market is driving the incessant growth of the Telemedicine market. Without 
Telemedicine, access to primary care services would remain strained or nearly impossible for 
numerous rural patients. In the coming years, Telemedicine will not only assuage the inaccessibility 
that rural practitioners and patients experience, but it will also broaden the range of services to the 
rural residents. 
Other trends observed globally include adoption of 3G and High Speed Package Access (HSPA), 
increasing use of wireless and web-based services, integration of various devices such as patient alert 
devices and vital signs recording devices, and hospitals’ integrated approach to healthcare delivery. 
Case Studies 
Mobile phones for health 
Application Area : Remote monitoring 
In 2005, engineers at Loughborough University developed a mobile phone health monitoring system to 
monitor diabetes and other diseases. The system allows doctors to use mobile phone networks to 
monitor up to four key medical signals (electrocardiogram heart signal, blood pressure, levels of blood 
glucose, and oxygen saturation levels) from patients who are on the move. Engineers from the UK and 
India are working to ‘miniaturize the system’ so that sensors are small enough to be carried by patients 
while procuring the necessary biomedical data. In Britain, the solution will be used to improve 
healthcare delivery, while in India it will connect ‘centres of excellence’ to hospitals and clinics in more 
remote areas. Over the next three years, clinical trials will occur in both the UK and India. 
Ÿ UK-based Loughborough University's engineers entered into a partnership with India to 
develop a unique mobile phone health monitoring system. 
Ÿ The system, which was first unveiled in 2005, uses a mobile phone to transmit a person's 
vital signs, including the complex electrocardiogram (ECG) heart signal, to a hospital or 
clinic anywhere in the world. 
Ÿ Presently, the system can transfer the signals pertaining to the ECG, blood pressure, 
oxygen saturation and blood glucose level. 
Ÿ IIT, Delhi, the All India Institute of Medical Sciences and Aligarh Muslim University and 
London's Kingston University joined hands to further develop the system. 
Ÿ The research team is aiming to miniaturize the system by designing sensors and mini-processors 
that are small enough to be carried by patients, and at the same time procure 
biomedical data. The network of sensors would be linked through a modem to mobile 
networks and the Internet, and to a hospital computer. Then, doctors can use this device 
to remotely monitor patients suffering from chronic diseases, like heart disease and 
diabetes. 
Ÿ The clinical trials of the system are going on in the UK and India. 
Support to Promote Maternal and Newborn Health 
The aim of the Telemedicine Support to Promote Maternal and Newborn Health in Remote Provinces of 
Mongolia project is to reduce infant and maternal mortality while addressing the gap between urban 
and rural healthcare services. The project started in September 2007 and continued till December 
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2010. Telemedicine services supported Aimags (province), with high-risk pregnancy consultations, 
prenatal ultrasound diagnostics, foetal monitoring and screening for cervical abnormalities using 
colposcopy. The services provided by the project were particularly important for women in remote 
rural regions who do not have the funding to travel for expert opinion. 
A total of 297 doctors, nurses and midwives were trained for this program between March and 
December 2009. A total of 598 cases were referred in 2009. Of these, 64% were obstetrical, 21% were 
gynaecological pathology and 15% were neonatal pathology. Only 36 of these cases were referred to 
Ulaanbaatar for treatment following the diagnosis, substantially saving the resources of rural residents 
that would otherwise have gone towards travel expenses. 
Opportune Breast Cancer Screening and Diagnosis Program 
In 2006, breast cancer became the leading cause of death among Mexican women between the age 
groups of 50 to 69. The Opportune Breast Cancer Screening and Diagnosis Program (OBCSDP) was 
meant to transcend economic and personnel barriers through the innovative deployment of ICTs. 
Aimed to reduce the breast cancer mortality rate in women, the program increased the national 
screening rates from 7.2% in 2007 to 21.6% by 2012. 
The Telemedicine network has a goal to screen 1.3 million women in a 30 month period between May 
2010 and December 2012. With over 34 million Mexican pesos (USD 2.8 million) of seed funding from 
the federal and state governments as well as not-for-profit groups, 30 screening sites in 11 states were 
linked by internet to two interpretation centers where results of the screenings could be viewed by 
radiologists. 
Due to challenges with internet connectivity in rural areas of Mexico, many Mexican communities lack 
the necessary bandwidth for internet protocol-based image transmission (necessary to transmit 
mammograms). To overcome this challenge, CDs were used for patient data transfer and long-term 
data (backup) storage. (Each carried four patient images (a full mammography) and up to four patient 
mammograms). CDs were privately or commercially couriered to the closest interpretation centre. 
However, results with this method took up to three weeks to be returned to individuals. 
Text to Change 
Sponsoring Organization and Partners: Celtel, AIDs Information Centre (AIC), Merck, and the Dutch 
Ministry of Foreign Affairs. Text to Change (TTC) program provided HIV/AIDS awareness via SMS based 
quiz to 15,000 mobile phone subscribers during three months in Uganda. TTC was founded with the 
goal of improving health education through the use of text messaging, which holds the advantages of 
anonymity and strong uptake among the population. Partnering with the mobile carrier Celtel and the 
local NGO AIDS Information Centre (AIC), TTC conducted a pilot program from February till April 2008 in 
the Mbarra region of Uganda, with the objective of increasing public knowledge of and changing 
behaviour regarding AIDS. The program aimed to encourage citizens to seek voluntary testing and 
counselling for HIV/AIDS. Free airtime was offered to users to encourage participation in the program. 
This was determined to be a powerful incentive since users could exchange the airtime with other 
subscribers as a type of currency. 
The quiz was interactive. When participants gave a wrong answer they received an SMS with the correct 
answer from the cell phone provider. The uptake rate of the survey was 17.4%. The quiz focused on two 
specific public health areas: 
Ÿ General knowledge about HIV transmission, and 
Ÿ Benefits of voluntary testing and counselling. 
15 
Telemedicine Concept
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
At the end of the quiz, a final SMS was sent to motivate participants to go for voluntary testing and 
counselling at the local health centre. Those who went to the centre were asked a final question: Was 
this the first time they had an HIV test? After testing, participants were requested to leave their mobile 
phone number so that post-test counselling could be arranged. For the people who came to the health 
centres through TTC, HIV testing and counselling was free of charge. Initial grants from Merck, the US 
pharmaceutical company and the Dutch Ministry of Foreign Affairs supported the program launch. 
Bringing critical pediatric care to a rural hospital 
Intel announced a comprehensive set of digital inclusion projects aimed at improving education, 
healthcare and economic development for Nigeria's 140 million people in 2007. With the support of 
the Federal Ministry of Health, Intel launched a pilot Telemedicine project that brings critical pediatric 
care to a rural hospital serving a region of 4.5 million people. They are now able to consult in real time 
with pediatric and surgical specialists in Abuja through the new Telemedicine system, which features 
video conferencing and high-speed broadband connections through Wimax (a long-range wireless 
technology). The pilot makes it possible for physicians to shorten both time and distance in getting to 
patients to treat them. The system connects one of Nigeria's leading medical institutions, the National 
Hospital in Abuja with the Federal Medical Centre in Bida, a rural 200-bed medical facility. Till now, 
patients who needed referrals from Bida were forced to travel at least 250 kilometres to reach 
specialists, a trip most could not afford. Bida has an acute need for care from pediatric medical 
specialists. In the project's first phase, a foetal monitoring capability will permit pediatrician to 
remotely and more quickly consult with medical staff and examine expectant mothers to monitor the 
progress of their pregnancies. Intel is also training medical practitioners and technical specialists at 
both hospitals to use the new technology tool. 
Telemedicine Concept 
16
Telemedicine in India 
The healthcare model in India is a three tier system. At the first tier are the primary centres and sub-centres 
that provide services at the village level. The secondary level comprises healthcare facilities 
located at the district level, which includes district hospitals, private clinics and small nursing homes 
with limited equipment and expertise. The third tier or tertiary level healthcare settings are through 
medical college hospitals, specialty, and super specialty private chains of hospitals generally located in 
urban areas. Besides, there are a few 
advanced medical institutes of national 
importance, having clinical, teaching and 
research facilities in various super specialties. 
Primary level includes Primary Healthcare 
Centres (PHC’s) and sub-centres at the village 
level equipped with a practitioner and 
facilities to provide first-aid or basic medical 
check-ups. However, many centres lack 
qualified practitioners, adequate medical supply, specialty solutions, connectivity and medical beds, 
etc. Secondary level includes District level hospitals, small private clinics and nursing homes with small 
equipment and facilities limited to providing basic medical diagnosis. However, In India they too lack 
specialty treatment facilities, high-end medical equipment and adequate number of beds. 
17 
Health care model in India 
Primary centers and sub-centers that 
provide services at the village level 
Healthcare facilities located at the district level 
including district hospitals, private clinics & small 
nursing homes with limited equipment and expertise 
Medical college hospitals, specialty, and 
super specialty private chains of hospitals 
generally located in urban areas 
Tier-1 
Tier-2 
Tier-3 
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International Telemedicine Congress - 2011
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Telehealth Report - 2011 
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Chart 4: Public spending as a % 
of total healthcare spend, 2007 
Tertiary level includes medical colleges, big private chains of hospitals and corporate hospitals situated 
in large urban areas. Facilities include high-end medical equipment, well qualified medical staff, etc. 
These institutions, however, service a small segment of the vast population of the country. 
Despite a steady increase in the number of medical establishments and improvement in India’s 
healthcare infrastructure, much remains to be accomplished. There still remains a severe shortage of 
sub centres, primary health centres, and community health centres. Lack of adequate healthcare is also 
reflected in the low density of healthcare personnel. India does not have a national health insurance 
policy or any other national healthcare guarantee program for its citizens. The existing three tier health 
care system is highly inadequate in providing quality healthcare services due to India’s increasing 
population and the growing demand for healthcare services. Growth in physical infrastructure i.e., 
healthcare facilities and hospitals is not sufficient to meet the current demand. 
The poor state of healthcare system in India may also be attributed to the lack of government funding 
on healthcare initiatives. As estimates reveal, per capita spending on healthcare by the Indian 
Government is far below international recommendations. The healthcare spend, when compared on 
the basis of public-private contribution, also depicts a skewed picture. Private sector contribution to 
the healthcare at approximately 74% is amongst the highest in the world. Public spending, on the other 
hand, is amongst the lowest in the world and is approximately 26% points lower than the global average. 
Indian Healthcare Market 
The Indian healthcare sector represented a USD 40 
billion industry in 2009. Hospitals accounted for 
approximately 50% of the market, pharma contributed 
25%,diagnostics with 10%, and medical equipment 
accounted for roughly 15%. The industry is expected to 
grow to USD 79 billion by 2012 and USD 280 billion by 
2020 at a CAGR of 21.5%. 
The Healthcare sector, in India, is at an inflection point and is poised for a healthy growth in the medium 
term. Healthcare spending is expected to grow to 8% of the GDP in 2012. 
A combination of demographic and economic factors is expected to bring increased healthcare 
coverage in India which is expected to drive the growth of the sector. India‘s rising population and 
income levels, along with a growing preference for private health services over public services, is 
augmenting the growth of the healthcare delivery market. Population growth and increased disposable 
income are expected to result in better healthcare awareness and more expenditure on healthcare. 
Telemedicine in India 
Indian healthcare 
spend as a % of GDP is 
less than half the 
global average 
Chart 3: Healthcare spending 
as a % of GDP, 2007 
% 
20 
15 
10 
5 
0 
US Brazil UK China India Global 
Per Capita spending as 
compared to other 
Countries is also very 
low in India 
Chart 5: Per Capita Healthcare 
spending, 2007 
USD 
8,000 
7,000 
6,000 
5,000 
4,000 
3,000 
2,000 
1,000 
0 
US UK Brazil China India Global 
Public healthcare 
spending in India is again 
half the global average, 
amongst the lowest in 
the world 
% 
100 
80 
60 
40 
20 
0 
US Brazil UK China India Global 
Chart 6: Healthcare industry in India 
% 
300 
250 
200 
150 
100 
50 
0 
CAGR 21.5% (2010-2020 ) 
2010 A 2012 E 2020 E
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Healthcare expenditure (public and private) in India is expected to increase by 15%. India has the 
potential to add nearly 1.74 million beds by 2025 with an investment of about USD 104 billion to fulfil 
the unmet needs. The demand for quality healthcare in India is burgeoning and there exists a huge 
supply gap. An additional 1.74 million beds are needed to achieve the target of two beds per 1,000 
populations by 2025. An additional 700,000 doctors will be required by 2025 to reach a ratio of one 
medical doctor per 1,000 individuals. To maintain the current doctor-to-nurse ratio of 2.2, an additional 
1,600,000 nurses will have to be trained by 2025. 
Population of India is expected to increase from about 1.21 billion in 2010-2011 to 1.4 billion by 2026. In 
addition, an expected increase of geriatric population from current 96 million to around 168 million by 
2026 represents a huge patient base and creates a market for preventive, curative and geriatric care 
opportunities. 
Households can benefit from an increase in disposable income from 14% in 2009-2010 to 26% in 2014- 
2015 making healthcare more affordable. There is likely to be a marked increase in the incidence of 
lifestyle-related diseases, such as cardiovascular, oncology and diabetes, when compared to the 
communicable and infectious diseases. Growing general awareness, patient preferences and better 
utilization of institutionalized care is expected as a result of increase in literacy rates. Lower direct taxes, 
higher depreciation on medical equipment, income tax exemption for five years to hospitals in rural 
areas, etc. are being provided by the Government to the sector to boost it. India is also emerging as a 
major medical tourist destination with medical tourism market expected to reach USD 2 billion by 2012. 
Telemedicine – Promising Future 
Telemedicine can embrace modern technology to widen healthcare accessibility in rural India and 
can be a solution for India’s healthcare woes. A vast country like India, with a population of over 1.2 
billion across 29 states and 6 Union Territories and governed by a federal system, needs affordable 
healthcare. 
“It is a fact that has not been accepted by policy makers that it is nearly 
impossible under the current rural infrastructure and payment terms to 
get good doctors to work in rural India. In addition, building healthcare 
facilities and maintaining them in rural India is financially unviable. So the 
current healthcare system will always be an ad hoc arrangement and a 
highly subsidized one while not being a lasting solution. Rural India needs 
to extensively leverage the 3G and WIMAX technology and adopt 
preventive care model to avoid pain, suffering and high cost of 
healthcare” 
Rajendra Pratap Gupta, Leading Global Healthcare Policy expert 
Telemedicine today has given the ability to the doctors to provide healthcare to the needy. It is taking 
modern healthcare to remote areas. Majority of diseases not requiring surgery are conducive to 
Telemedicine. It allows training of medical personnel across the country to provide services to the 
patients in remote areas. Over the last five years; both price and complexity of this technology has 
decreased making Telemedicine economically viable. Telemedicine, as a branch of diagnosis and 
treatment, should be encouraged and widely implemented to help ensure availability and accessibility 
of care to all areas in spite of infrastructural inefficiencies. 
19 
Telemedicine in India
20 
Telemedicine is the convergence of communication technology, 
information technology, biomedical engineering and medical 
science. 
In India, early forms of Telemedicine used telephone and radio 
followed by communication through fiber optic cables. Lately, 
Telemedicine has evolved to utilizing video telephony, advanced 
diagnostic methods supported by distributed client/server 
applications, and telemedical devices to support medical care at 
homes. This evolution in Telemedicine is through satellite 
communication developing from ‘Point to Point System’ (one 
remote location connected to one main location) to ‘Point to Multi 
Point System’ (one remote location at a time connected to many 
main locations), and finally to ‘Multi Point to Multi Point System’ 
(several remote locations simultaneously connected to main 
locations in different geographical locations). 
Chart 7: Pillars of Telemedicine 
Video Conferencing 
District Hospital 
Telemedicine 
Specialty Hospital 
Panel of Doctors 
Chart 8: Representative Telemedicine structure 
Remote Location 
Ÿ Regional/secondary care hospitals 
Ÿ Rural health care services 
Ÿ Primary care 
Ÿ Consultation and diagnosis 
Ÿ Patient education and follow-up 
Ÿ Professional education 
Ÿ Continuing medical education 
Ÿ Administrative services 
Main Location 
Ÿ Regional/tertiary care hospital 
Ÿ Consultation 
Ÿ Screening and diagnosis 
Ÿ Monitoring 
Ÿ procedure guidance 
Ÿ Patient education & follow-up 
Ÿ Professional education 
Ÿ Continuing medical education 
Ÿ Administrative services 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Telemedicine in India 
Medical 
Science 
Communication 
Technology 
Biomedical 
Engineering 
Information 
Technology
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
The Telemedicine system comprises of customized hardware and software at the “Patient” site and the 
“Specialist doctor” site, with diagnostic equipment like ECG, X-ray, Pathology, Microscope/Camera, etc. 
provided at the patient end. They are connected through a Very Small Aperture Terminal (VSAT), WIFI, 
and Broadband, controlled by a Network Hub Station. Through a Telemedicine system that consists of a 
simple computer with communication systems, the medical images and other information pertaining 
to the patients can be sent to the specialist doctors, either in advance or on a real time basis through the 
satellite link in the form of Digital Data Packets. These packets are received at the specialist centre, the 
images and other information are reconstructed so that the specialist doctor can study the data, 
perform diagnosis, interact with the patient and suggest the appropriate treatment during a Video 
Conference with the patient end. Telemedicine facility thus enables the specialist doctor and the 
patient, separated by a distance, to interact visually and talk to each other. 
Major components of Telemedicine include : 
Ÿ Telemedicine workstation 
Ÿ Document and radiographic film digitizer 
Ÿ Ultrasound device, ECG, MRI, Scanner, X-Ray 
Ÿ Processing unit and keyboard 
Ÿ Audio Module – speakers, headphones, volume and base control 
Ÿ Camera - lens, image sensor, pixels, resolution, illumination range, video output signal, 
power zoom 
Ÿ Microphone 
Ÿ Monitor – resolution, speakers, signal type, dot pitch 
Ÿ Central power switch, power requirements 
Ÿ Communication platform allowing compatibility with networks (WAN) – SW-56, ATM, ISDN, 
satellites, and networks (LAN) - Ethernet 
Ÿ Connector panel – LAN, WAN, phone network, audio and video input and output ports, 
radiographic film digitizer, CD-ROM, etc. 
Ÿ Telemedicine peripheral devices – Otoscope, Dermatoscope, Stethoscope, Ophthalmoscope, etc. 
Ÿ Telecommunication network architecture 
Ÿ Plain Old Telephone System (POTS) - Analog telephone lines 
Ÿ Dial-up digital telephone lines - Integrated Service Digital Networks (ISDN) and Switched-56 
(SW-56) 
Ÿ Asynchronous Transfer Mode (ATM) 
Ÿ Satellite – Geo-synchronous and Low Earth Orbit (LEO) 
Ÿ Microwave 
Ÿ Coaxial Cable, Fibre Optics 
Ÿ Asymmetric Digital Subscriber Line (ADSL) 
Ÿ Various Digital Subscriber Line (xDSL) 
Ÿ Internet or Modem 
Ÿ Virtual Private Networks 
Ÿ Hospital and Regional Health Networks 
Ÿ Software Architecture 
Ÿ Human intervention 
Ÿ Physicians – General practitioners, specialists and medical students, etc. 
Ÿ Nurses – Registered Nurses (RN), Licensed Practical Nurses (LPN) and nursing students 
Ÿ Allied Health Professionals – occupational therapists, physiotherapists, etc. 
Ÿ Health Administrators, Educators and Researchers 
Ÿ Technicians 
Ÿ Patients and their families, informal care givers 
Ÿ Telehealth project Managers and site coordinators. 
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Telemedicine in India
22 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
mHealth 
mHealth, also known as Mobile health, leverages mobile devices and ICT to deliver health services and 
information exchange which can increase access, affordability, and quality of healthcare significantly. 
Telemedicine in India 
Today’s Technology Tomorrow’s Technology 
Hardware 
Ÿ Features suitable for basic 
mHealth services available on 
mobile phones 
Ÿ Mobiles can access web, 
download pictures, etc. 
Ÿ Internet speeds limit the 
number of applications which 
can be used 
Ÿ Most laptops, handhelds, PDAs 
easily access wireless networks 
where available 
Ÿ Cell phones and mobile 
computers become less discrete 
Ÿ Larger displays and Solar 
chargers for mobiles 
Software and applications 
Ÿ Widely available for laptop and 
handhelds 
Ÿ Availability of handsets with 
open architecture. 
Ÿ Open source software 
accelerate application 
development and reduce cost 
Network access 
Ÿ Cellular usage common in urban 
areas compared to rural areas 
Ÿ Broadband, internet access is 
limited in several geographies 
and also costly 
Ÿ Network transparency 
Ÿ Wireless networks create almost 
universal Internet access 
Standards 
Ÿ Policies and standards required 
for Broadband 
Ÿ Allowance of greater range of 
services, provider 
Ÿ Partnerships 
Services 
Ÿ Education/awareness programs 
Ÿ Medication monitoring 
Ÿ Data collection services 
Ÿ Disease tracking 
Ÿ Remote monitoring 
Ÿ More sophisticated 
diagnoses/consultations, e.g., 
Teleradiology, teleopthamology. 
Ÿ More effective use of healthcare 
workers 
Ÿ More ‘personal’ mHealth 
services 
Ÿ Services for travel-restricted 
Chart 9: Mobile technology evolution 
Technology 
advancement 
WIMAX availability for 
Pcs 
Open source systems 
Greater bandwidth 
IP access for standards and 
decisions over licensesI 
Better services offerings
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
It involves the use and capitalization of a mobile phone’s core utility of voice and short messaging 
service (SMS), as well as more complex functionalities and applications including general packet radio 
service (GPRS), third and fourth generation mobile telecommunications (3G and 4G systems), global 
positioning system (GPS) and Bluetooth technology. 
As 3G swings in India with over 900 million mobile phone connections and Android phones become 
increasingly available, the opportunity for high value mobile enabled services is tremendous. Two 
industries that have already tapped into the ubiquity of mobile phones in a big way are entertainment 
and financial services, with applications ranging from music downloads to banking that are attracting 
swaths of users and investments. But mHealth has only scratched the surface in India largely because 
there is a lack of awareness among patients and doctors about what mHealth is and what benefit it can 
provide. 
23 
Table 2: mHealth – A win-win for all 
Ÿ Improved treatment, education, and illness 
prevention 
Ÿ Improved operational efficiencies, improved 
quality, and effectiveness of healthcare 
Ÿ More effective delivery of healthcare 
services 
Ÿ Improved operational efficiencies 
Ÿ Organizational mission closely ties to 
program success 
Ÿ Expansion or scale of program 
Ÿ Revenue from hardware sales 
Ÿ Strategic market positioning for short and 
long term brand and business development 
Ÿ Revenue from training or supporting 
contracts 
Ÿ Opportunities for placement in network 
expansion projects 
Ÿ Revenue from service fees through increased 
subscribers 
Ÿ Revenue from handset device sales 
Ÿ Expanded mobile subscriber base for 
increased revenue from other services 
Ÿ Revenue from application license fees 
Ÿ Revenue from application customization fees 
Ÿ Revenue from training contracts, hardware 
support system 
Ÿ Opportunity to become a standard in 
mHealth 
Ÿ Potential for add-on sales as program scales 
Patient: Recipient of healthcare service 
Caregiver: Delivering healthcare services like 
physicians, nurses, midwives, healthcare 
workers 
Project management: The entity responsible for 
direct management of the project including 
business and programmatic, like a government 
agency or independent organization 
Equipment provider: Generally the 
manufacturer of any hardware relative to the 
services including customer devices or network 
devices. May also provide training, support to 
operator or health care practitioner. 
Service provider: The mobile telephony 
operator 
Application Solutions provider: The entity 
providing mHealth application, either as a 
standalone software application or an integrated 
application 
Telemedicine in India
24 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Telemedicine in India 
Table 3: Overview of mHealth use case findings across the Healthcare Continuum 
ŸAccessibility of patient data; reduction in 
procedures and tests; fewer medical errors 
ŸImproved patient access to physicians; 
increased billable hours 
ŸLower administrative costs; faster service 
ŸImproved supply chain efficiency/accuracy; 
increased productivity; lower risk of 
compliance breaches 
ŸAccurate and timely feedback to patients; 
ease of coordinating remote providers; 
streamlined consultations 
ŸRegular patient monitoring; increased 
productivity; reduced travel time 
ŸReal-time updates of patient data; ability to 
offer “untethered” care outside of traditional 
settings 
ŸEase of locating specialists and services in 
network; lower costs with drug cost-comparison 
shopping; increased consumer 
usage of plan benefits; better management of 
medical expense accounts 
ŸIncreased accuracy and lower costs; 
compliance-certified apps meet regulatory 
requirements 
ŸCommunity-based retail stores use mobility to 
improve ACO care coordination 
ŸReal-time access to data to advise doctors and 
patients on drug therapies and associated 
risks 
ŸEnables pharmacists to interact with patients 
“in the aisles” with access to real-time patient 
data 
ŸMore efficient and accurate order processing; 
improved compliance in sample distribution; 
digital signature capture 
ŸAbility to identify and catalog worldwide 
epidemiologic trends 
ŸInteractive apps to identify appropriate care 
providers 
ŸAccurate and timely feedback of health data; 
rapid throughput of test results to providers 
ŸImproved care/lower costs through home 
healthcare 
ŸGreater emphasis on patient-centered care; 
reduced isolation of convalescing patients 
ŸIncreased knowledge of cost/benefit trade-offs 
ŸElectronic Health Records, 
Health Information Exchange 
ŸTelehealth/remote care 
ŸPatient self-registration using 
tablets 
ŸBar code scanning 
ŸElectronic Health Records, 
Health Information Exchange 
ŸTelehealth/remote care 
ŸPeripheral devices integrated 
into mHealth solutions 
ŸConsumer self-help apps 
ŸMobile apps replace paper-based 
forms; bar code 
scanning 
ŸDrug reference and drug 
interaction apps 
ŸMobile access to back-office 
ŸMobile CRM apps for 
“detail” sales representatives 
ŸElectronic Health Records, 
Health Information Exchange 
ŸSymptom checker 
ŸApps with integrated 
peripheral devices 
ŸTelehealth/remote care 
ŸSocial engagement-based 
solutions 
Hospitals 
Doctors, Nurses 
Insurance 
Companies 
Suppliers 
Pharmacies 
Drug and Medical 
Supply CRM 
Federal Agencies 
Consumers
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
A February 2011 report authored by Pyramid Research found that more than 200 million mobile health 
applications are used by doctors and patients today, and more than 600 million medical apps will be 
available by 2012. (Source: Pyramid Research) 
According to a February 2011 study by Aptilon, 79 percent of physicians prefer the iPad, compared with 
12 percent of doctors who prefer a Windows-based tablet and nine percent who prefer an Android 
device. 
An InfoWorld article published in May 2011 cites a study by RNCOS. The study estimates healthcare IT 
spending in the United States is expected to reach $40 billion in 2011. Of that, the mobile health market 
is estimated to be 5.3 percent of total healthcare IT spending. 
Projections indicate that over one third of all smartphone holders worldwide or 1.4 billion people 
globally, will be using mHealth solutions within the next five years, according to research2guidance. 
Through informal polling, Epocrates estimates up to 70 percent of medical schools are having a mobile 
device requirement or recommendation for medical students. The average physician can re-purpose 
130 administrative hours each year by using a mHealth solution. 
According to Galvin Consulting, August 2011, many healthcare professionals are looking to new 
mobility technologies as a way to solve some of the industry’s most pressing problems. These thought 
leaders believe society is on the cusp of dynamic change in the way healthcare is both provided and 
consumed. Mobility in the general workforce is expected to increase at an unprecedented rate in the 
coming years, both in the United States and other countries, including India. 
In developing countries such as India, mHealth shows special promise in specific mHealth applications, 
including: 
Ÿ Widespread care through telemedicine and “virtual hospitals”. 
Ÿ Improved medical data processing as a result of direct data input into mobile devices. 
Ÿ Improved patient care as physicians interact directly within local communities. 
Ÿ Early warnings of shifting health trends, including emerging and infectious diseases, as large 
amounts of data from mobile devices are collected and analyzed. 
Ÿ Improved disaster response efforts for earthquakes, floods and other disasters as first responders 
use mobile devices to identify areas most in need of assistance. 
Over and above these benefits are improved accuracy throughout the healthcare system and earlier 
detection of medical issues that help to prevent expensive and serious complications later. 
Current state of Telemedicine in India 
Telemedicine practice was first initiated in Lucknow and Chennai in 1997. In Kerala, first unit of 
Telemedicine was formed at the Medical College, Thiruvananthapuram in 2003. Recognizing the 
common interest of health and community welfare, Telemedicine was promoted for the availability of 
quality medical services to the needy, irrespective of socio economic and geographic disparities like 
rural, remote, and inaccessible places. 
During the National Conference on Telemedicine held in Lucknow in April 2001, the participants 
resolved to form a scientific society dedicated to Telemedicine at national level and carry out an annual 
scientific event pending a formal registration. Thus the Telemedicine Society of India (TSI) was born and 
all the participants signed a resolution to this effect and were made the founding members. It has been 
a long journey for the TSI. Although the efforts had started from 1996, yet it took time to reach this 
position. Having survived infancy, it is now coming of age. In all developing countries, there is an acute 
shortage of resources in the health care sector. In emerging economies like India, there has been an 
25 
Telemedicine in India
exponential and an unprecedented increase in the availability of Information and Communication 
Technology. ICT has provided a unique opportunity of bridging the urban rural health divide. For 
Telehealth to take off, it had to be embraced by all the stakeholders; the Government, private sector, 
public sector, entrepreneurs, etc. 
The first TSI meeting was held in Lucknow in 2001. Its focus was on rural medicine. Initial support from 
ISRO played a very vital role in the growth of Telemedicine in India. The official TSI meet took place in 
Bangalore in 2005 when the smooth life of TSI began. Then the annual successive meets took place in 
Delhi (2006), Chennai (2007), Chandigarh (2008), Pune (2009), Bhubaneshwar (2010), and Mumbai 
(2011). The first TSI chapter was started in 2010 in Bhubaneswar. Over a period of time, TSI has 
extended their services to Indian army. They set up Telemedicine units initially in the southern 
command and subsequently in the central command. Training programs were organized exclusively for 
officers. They have also pioneered in partnerships with Uganda, Mauritius, Nigeria, the Netherlands, 
etc. As of now, TSI has provided teleconsultations in various specialties to 29 countries in Africa, and 
also initiated teleconferences with many countries including Japan, US, Saudi Arabia and Hong Kong. 
India is beginning to make strides in the areas of Telemedicine and eHealth. Most of the Telemedicine 
activities are in project mode, supported by the ISRO and the Department of Information Technology 
and being implemented through state governments. A few corporate hospitals have developed their 
own Telemedicine networks, prominent among them being the Apollo Telemedicine Networking 
Foundation, which commenced Telemedicine operations as early as January 2000. Around 500 
Telemedicine nodes are in place across the country. 
Telemedicine has a market size of USD 70 – 110 million in India. It is expected to grow at very high CAGR 
of approximately 35% over the next five years to reach USD 314 – 493 million by 2016. The full potential 
of the Telemedicine market could be realized with appropriate stakeholder vision and better adoption. 
Key growth drivers are: 
Ÿ Low cost and wide reach over satellite or fiber optic bandwidth 
Ÿ Lack of disease management framework 
Ÿ Lack of healthcare facilities in far-off regions 
Ÿ Reduced technology cost and availability of qualified technical personnel 
Ÿ Shortage of qualified medical professionals 
Ÿ Increased government focus on healthcare for all 
Ÿ Urban-rural divide causing disparity in medical facilities 
Ÿ Dedicated satellite for health communications from ISRO 
Ÿ Growth of Information and Communications Technology as a sector 
Ÿ National Telemedicine grid to connect practitioners and institutions 
Ÿ PPP model for development of healthcare infrastructure 
The key growth driver for Telemedicine is India is its technologically advanced ICT sector which is self-sufficient 
in meeting its needs of hardware, software, connectivity and services. Therefore, ICT 
technologies have the potential of making healthcare affordable for India, especially in rural India. This 
success can be further reinforced if these ICT technologies are integrated into existing health-care 
delivery systems. In the last decade, there has been active investment for development of Telemedicine 
in India, but considering the demographic spread, this investment is not sufficient for such a large 
country. The scale of Telemedicine services in India has been limited so far to medical transcription, 
health awareness through portals, Telemedicine and hospital management system and customer 
service using the internet. While globally and particularly in Africa, advanced technologies such as 3G 
services are used efficiently for providing healthcare solutions to remote villages, the use of 
communication devices such as mobile phones or conferencing solutions for Telemedicine in India has 
been limited. 
26 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Telemedicine in India
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
“In the next 3-5 years, I can well foresee a fight between Tablets & Smart- 
Phones, a fight between Windows, Apple & Android rather than a fight 
between a user and non-user of mHealth.” 
Rajendra Pratap Gupta, 
Leading Healthcare Policy Expert 
“mHealth is more relevant in India than conventional eHealth, as access 
to PCs, laptops and broadband is far less than access to mobile phones. 
India has just 12 million broadband connections, 24 million internet 
subscribers and 85 million PCs as compared to 881 million mobile 
phones.” 
Prof. K. Ganapathy, 
President of Telemedicine Society of India and President of Apollo Telemedicine Foundation 
Utilizing wireless to access the internet is steadily increasing and telecom operators in India see this 
as a growth segment. One would not like to call mHealth a killer application, but considering that 
health is a truly universal requirement, this would perhaps be an apt description. The ubiquitous all-pervading 
universally available mobile phone can now be used as a tool, and an enabler to deliver 
healthcare. There are unlimited opportunities and strategies for using the mobile in implementing 
mHealth in hospitals, insurance companies, Pharma companies, etc. With thousands of health 
applications, the mobile phone can soon become a hand held hospital. 
According to Dr. P S Ramkumar, Director of Applied Cognition Systems, “Practical mHealth will take time, 
although the concept is easy to sell due to large scale user familiarity with mobile phones. Although 
mobile communication has equipped the country with approximately 881 million phones, a recent 
survey has found that, of 30 Tele-Health projects only two had intersect with mobile phones while 60% 
used free satellite connections provided by government initiatives. The RTBI group of IITM in 
collaboration with LIRNEasia, Sri Lanka, National Centre for Biological Sciences, Bangalore and 
Department of Health and Family Welfare, Tamil Nadu, have demonstrated adoption of ordinary text 
based cell phones by rural health workers showing improvement in disease surveillance and response 
time. Apollo Telemedicine network foundation has demonstrated Telemedicine application on mobile 
platforms on 3G networks in collaboration with Ericsson’s Gram-Jyothi program demonstrating Tele-presentation 
of radiology images, ECG, etc. 
“It is not possible for 
everyone to own a 
computer or to use a 
computer for health, 
but smart phones 
comes in handy, and 
so, for sure, all 
aspects of healthcare 
will finally converge 
to mHealth” 
Rajendra Pratap Gupta, 
Leading Healthcare Policy Expert 
27 
Telemedicine in India 
Growth of Health Apps by Platform over six month period 
Platform 
Total Apps as 
of 2/2010 
New Apps 
launched: 
/2010 – 
9/2010 
Total Apps as 
of 9/2010 Growth 
Apple 
AppStore 
Health Apps 
4,276 2,860 7,136 66.6% 
Google 
Android 
Health Apps 
505 791 1,296 156.6% 
Blackberry 
App World 
Health Apps 
140 198 338 141.4%
However, the system lacks legal clarity on the question of who is accountable for delayed data, 
inaccurate transmission and privacy/security loss of the data” 
A truly different way of patient empowerment, mHealth can bridge the urban rural health divide. With 
50 mobile phones being sold every second, with an urban teledensity of 113% and a rural teledensity of 
49%, India should certainly be poised to incorporate mHealth into the very fabric of its healthcare 
delivery system. 
Key stakeholders driving Telemedicine 
Tele medicine as a concept has multiple areas of application which are not only based on advantages 
key to the medical field but also help in the business end by accessing more people and reducing costs 
for all parties involved. This has led the various possible stakeholders in India to actively implement and 
promote Telemedicine. A key part of Telemedicine, m-Health or mobile driven health services is 
receiving the most amount of attention. This is fuelled by India’s unique mobile service cost structure 
combined with the huge disparate population and low cost of mobile handsets. The major stake 
holders in the progress of Telemedicine can be broadly classified under three categories : 
1. Government and Government Bodies 
This includes organizations that facilitate growth of Telemedicine through policy initiatives, and 
financial backing. It consists of organizations such as the Ministry of Health and Family Affairs, the 
Department of Information Technology, Ministry of Communication and IT and the various state 
governments. In India, various departments have been proactive in launching initiatives and partnering 
with various other organizations to promote Telemedicine. 
Ÿ Ministry of Health and Family Welfare (MoHFW), Government of India 
There is a very structured and planned approach toward Telemedicine in India. This is evident from the 
setup of the National Task Force on Telemedicine under the chairmanship of Secretary, Union Ministry 
of Health and Family Welfare, incorporating members from various concerned ministries of the union 
government e.g. Health, Communication & Information Technology and Space; technical agencies e.g. 
Indian Space Research Organization, Indian Council of Medical Research, Medical Council of India, 
Centre for Development of Advanced Computing; academic medical institutions and corporate 
hospitals practicing Telemedicine actively. 
Ÿ State Governments 
A large number of state governments have shown positive support for the development and inclusion 
of telemedical facilities in their state. In Odisha and Uttarakhand, the secondary-level hospitals have 
now been linked to SGPGIMS at Lucknow for specialty consultation with the support of the 
governments. ISRO together with the government of Chhattisgarh has established a state-wide 
network linking the state government medical colleges at Raipur and Bilaspur and other premier 
hospitals across the country. Similarly, the Rajasthan state government has established a Telemedicine 
network between six state medical colleges and 32 district hospitals and six mobile vans with ISRO’s aid. 
The Karnataka State Telemedicine Network Project, run by an autonomous trust formed by the state 
government, has set up 30 nodes in collaboration with ISRO. The Punjab go vernment has also 
launched a Telemedicine project, with state-of-the-art facilities at the Government Medical College 
and Hospital to link the five polyclinics set up in the state. Many state governments, along with the 
department of IT, have started establishing Telemedicine networks with state specialty hospitals 
connected with different district and smaller health centres. Some of them are the governments of 
Tripura, West Bengal, Himachal Pradesh, Punjab, Tamil Nadu and Kerala. 
28 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Telemedicine in India
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Ÿ Ministry of External Affairs Projects 
The progress in Telemedicine is not restricted within domestic networking and resource pooling. The 
ministry of External affairs has initiated a SAARC Telemedicine Network project that connects one or 
two hospitals in each of the SAARC countries with three to four super-specialty hospitals in India. The 
super specialty hospitals in India include AIIMS, SGPGIMS, PGIMER at Chandigarh and the CARE 
Hospital at Hyderabad. 
2.Technology Providers 
By collaborating with state governments the Department of Information Technology (DIT) and 
Ministry of Communication and IT (MCIT), has established a Telemedicine network of more than 
100 nodes all over India. The medical network includes: 
29 
ŸWest Bengal for diagnosis and monitoring of tropical diseases. 
Ÿ Kerala and Tamil Nadu Oncology Network for facilitating cancer care. 
Ÿ North-eastern and Himachal Pradesh hilly states for specialty health care access. 
Another initiative of the ministry, the Pan-African eNetwork Project, along with Telecommunications 
Consultants India Ltd. (TCIL) is that of setting up a VSAT-based Telemedicine and tele-education 
infrastructure for African countries in 53 nations of the African Union. 
Ÿ Various technology providers 
This group includes the various companies such as Ericsson, Texas Instruments, CISCO Systems, C-DAC, 
Sony which provide specialized hardware and software solutions aimed at innovative telemedical 
services. The category also includes the various stakeholders which provide the sustaining 
infrastructure and connectivity support. In India some of the players so far have been ISRO, Aircel, Airtel 
and IBM. The contribution of these stake holders has been in terms of forging relationships that prove 
to be socio-economically beneficial to the country. With innovation in services and improved 
efficiencies in communication and support tech, these groups of stakeholders hold the key to the long 
term growth and commitment to Telemedicine in India. 
Ÿ Indian Space Research Organization (ISRO) 
ISRO’s pilot Telemedicine project was launched in 2001 with the aim of introducing the Telemedicine 
facility to the grassroots level population as a part of “proof of concept technology demonstration” 
program. The Telemedicine facility connects the remote District hospitals/health Centres with super 
specialty hospitals in cities, through the INSAT Satellites for providing expert consultation to the needy 
and underserved population. 
Telemedicine facilities are established at many remote rural district hospitals in many states and union 
territories of the country including Jammu & Kashmir, Andaman & Nicobar Islands, Lakshadweep 
Islands, and North Eastern States, etc. State level Telemedicine networks are established in Karnataka, 
Kerala, Rajasthan, Maharashtra, Odisha and Chhattisgarh. Many interior districts in Odisha, Madhya 
Pradesh, Andhra Pradesh, Punjab, West Bengal and Gujarat have the Telemedicine facility. 
Presently, ISRO’s Telemedicine Network has enabled 382 Hospitals with the Telemedicine facility. 306 
among them are remote/rural/district hospital/health centres and 16 are mobile Telemedicine units, 
connected to 60 Super Specialty Hospitals located in the major cities. The mobile vans are extensively 
used for tele-ophthalmology, diabetic screening, mammography, childcare and community health. The 
Mobile Teleopthalmology facilities provide services to the rural population in ophthalmology care 
including village level eye camps and vision screening for cataract /glaucoma / diabetic retinopathy. 
About 150 thousand patients are getting the benefits of Telemedicine every year. 
Telemedicine in India
30 
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
Ÿ The Centre for Development of Advanced Computing (C-DAC) 
C-DAC has been working in the area of Health Informatics since early 90s. It has developed several 
solutions till date in this area. Notably CDAC developed and deployed the first indigenously developed 
total hospital information system (HIS) software in collaboration with the Sanjay Gandhi Post Graduate 
Institute of Medical Sciences (SGPGIMS) at Lucknow in 1998. 
Currently, there are more than 16 hardware and software Telemedicine activities undertaken by C-DAC. 
3. Hospitals and Bio-medical Institutions 
The core part of Telemedicine, be it e-health, mHealth or medical research is the medicine. This is 
driven by the innovation and standards set by the medical fraternity. Innovation in terms of pioneering 
mobility in medical instrument, spreading awareness of the benefits, reliability and correct use of tele 
medical techniques are just a few critical roles taken on by organisations under this stake holder 
category. In India, hospitals and institutes across varied locations and sizes of operation are continuing 
to be a part of many initiatives. The most notable contributions have been seen from the Apollo Group 
and SPGIMS. Other significant participants and premier medical institutions include All-India Institute 
of Medical Sciences (AIIMS), New Delhi (Jammu & Kashmir, Haryana, Odisha, North East states 
network), PGIMER12, Chandigarh (Punjab and Himachal state network),Sri Ramachandra Medical 
College and Research Institute (Andaman & Nicobar Islands), Tata Memorial Hospital and Sir Ganga 
Ram Hospital, New Delhi, The Amrita Institute of Medical Sciences (AIMS), The Asia Heart Foundation, 
Fortis Hospital, Narayana Hrudayalaya, and Escorts Heart Institute and Research Centre . 
Ÿ The Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) 
SGPGIMS, since its inception, has been actively involved in promoting Telemedicine. It has helped in 
networking 14 national and international partner nodes and in carrying out tele-education and tele-healthcare 
activities. It is also actively involved in various research and development activities in 
collaboration with its technical partners. The institute is also credited with establishing the School of 
Telemedicine and Biomedical Informatics to train workers in this upcoming field. 
Ÿ Apollo Hospitals 
Amongst the latest initiatives, Apollo hospitals is planning to open 1,000 Telemedicine centres in the 
next three years (2011-14, 1000 days) and is also actively involved in various other eHealth activities, 
having done over 69,000 tele consultations till date. Apollo Hospitals along with Aircel, has also 
launched the first Telehealthcare delivery on the mobile for consumers in India. In the past, Ericsson 
and Apollo had collaborated for a three-month Gramjyoti project, aimed at exploring benefits that can 
be met for rural India with the advent of internet connectivity and bridging the digital divide. Gramjyoti 
covered around 18 villages and 15 towns. 
In September 2010, Apollo Hospitals joined hands with pan-India telecom operator Aircel, to launch 
the first telehealthcare delivery on the mobile for consumers in India. With a subscriber base of more 
than 45 million, Aircel is India’s fifth largest service provider, making it an ideal partner for Apollo to 
launch a mobile healthcare initiative, initially via two dynamic products – Tele Medicine and Tele Triage. 
Role of Telemedicine Society of India in promoting Telemedicine 
TSI promotes and encourages development, advancement and research in the science of Telemedicine 
and its associated fields. It has constantly played a major role in boosting the application of 
Telemedicine technology in clinical care, education and research in the health sector. TSI fosters 
networking and collaboration among interest groups in Telemedicine technology and professionals 
from different streams of science, health care providers, policy makers, NGOs and industry. 
Telemedicine in India
Telehealth Report - 2011 
with proceedings of 
International Telemedicine Congress - 2011 
It promotes training of students, health professional, research fellows and technicians, in various 
aspects of Telemedicine. TSI coordinates with academic institutions and Medical Council of India, 
AICTE, DOECC and regulating agencies in developing curriculum for Telemedicine training courses and 
incorporates appropriate modules in the Medical, Dental and Paramedical training programs. TSI has 
been arranging regular scientific meetings, symposia, seminars and workshops for Telemedicine. It is 
heading the development of appropriate clinical and industry policies and standards. TSI spreads 
knowledge in Telemedicine field by publishing brochures, periodicals, journals and has also created an 
exclusive web site for the society and regularly updates it with Telemedicine news. TSI works in close 
collaboration with scientific organizations and the industry in development and implementation of 
innovative products & services related to Telehealth. TSI also organizes trade exhibitions during annual 
meetings of the society. 
Public Private Partnership (PPP) 
An example of a Telemedicine public-private partnership is the collaboration of Narayana Hrudayalaya 
with the government and ISRO at Chamarajanagar District Hospital (Govt. owned), which is 185 km 
away from the super specialty cardiac care hospital situated in Bangalore, Karnataka. The network 
helps provide remote cardiac care to the local population of Chamarajanagar. According to Dr. Devi 
Prasad Shetty, Chairman, Narayana Hrudayalaya, the unit has treated about 52,000 patients since its 
inception in 2002. 
An impact study by an independent evaluating agency on 1,000 patients at the district hospital has 
reported that the patients who availed Telemedicine consultations spent only 19% of the cost they 
would have spent if there was a need for them to travel to the nearest city for similar treatment. 
The Tripura Vision Centre Project is a novel and innovative project in delivering preventive and primary 
eye care services to remote and underserved areas of Tripura, in North East India. Established in April 
2007, the project was designed by IL&FS-ETS, a social infrastructure initiative, in collaboration with 
Aravind Eye care system, for the State Department of Health. Services are rendered through 40 vision 
care systems (VC), staffed with trained paramedical ophthalmic assistants. Situated in the premises of 
Community Information Centre (CICs), the VC can leverage the Tripura State Wide Area Network 
(TSWAN) and existing infrastructure to connect to the base hospital, IndiraGandhi Memorial (IGM) 
Hospital, situated in the state capital of Agartala. Here, outpatient department ophthalmologists 
provide remote consultations through video conferencing and application modules. Preliminary 
treatment options like prescriptions and spectacles are provided online. Only those requiring special 
care like surgeries or complicated interventions are required to visit the hospital, thus keeping a check 
on the logistics and expenditure. 
Since its inception, the project has now expanded to 35 centres, having screened 71,000 patients till 
August 2010, among whom approximately 5,000 were referred to the base hospital. It has been 
estimated that each VC screens around 100 patients per month, thereby having a large impact on the 
healthcare delivery. The project was recognized by the Government of India and received the National 
e-Governance Award in 2009. 
31 
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Telehealth Report - India

  • 2. International Telemedicine Congress - 2011 Foreword 1 Editorial 2 Executive Summary 4 Telemedicon 2011 5 Telemedicine Concept 6 Telemedicine in India 17 Initiatives 32 Opportunities and Challenges 45 Industry Speaks 53 Business Models 58 Learning and Resources 60 Continua Health Alliance 65 Roadmap Ahead 67 References 71 Telehealth Report - 2011 with proceedings of Contents
  • 3. Rajendra Pratap Gupta International Healthcare Expert & Chairman, Organizing Committee International Telemedicine Congress – Telemedicon’11 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 1Foreword India is presently building on its healthcare system, and the 12th Five Year Plan has been referred to as the ‘Plan for Health’ ! Now is the right time for the policy makers to ensure that technology is embedded in all programs that the Government is planning to rollout for healthcare delivery. In specific, mHealth has tremendous potential to reduce costs, improve the reach and access to healthcare, make the healthcare system more outcome driven, and more importantly, help in establishing an ‘empowered patient’. With approximately 900+ million cell phones, healthcare in India will converge to mHealth, and ultimately, this is where all practitioners, payers and users will converge too! It is time to look at mHealth as a tool for ‘Inclusive Healthcare’ . Without mHealth,‘Universal Healthcare’ will just remain a dream ! Being personally involved in many mHealth & Telemedicine ventures and policy initiatives, I have always felt that when it comes to Telemedicine & mHealth, there is no concrete report that can fill in the readers with the detailed and up-to-date information, and so this attempt to come out with the first ‘Telehealth Report’- 2011. We have done our best to ensure that the report is accurate and full of facts from the users, policy makers and industry point of view. Still, this report could have inadvertent errors or short comings, as it usually happens with the so called ‘First Timers’. Please feel free to write back for any suggestions you might have . I do hope that this report will be of immense help to users, providers and policy makers for mhealth & eHealth - not just in India, but across the world . I do look forward to your comments & feed back. Yours in good health Member, Healthcare, Quality Council of India President, Disease Management Association of India Chairman, Board of Directors, HIMSS Asia Pacific India Chapter Co-Chair, Sub-Group on Chronic Diseases, Confederation of Indian Industry Member, Governing Council, Telemedicine Society of India Member, Board of Directors, Care Continuum Alliance, Washington, USA Email : chairman@telemedicinecongress.com www.telemedicinecongress.com
  • 4. Dr. Sam Pitroda Advisor to the Prime Minister of India on Public Information and Innovations Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 2 Editorial Technological advancements have come a long way from the time of the great Industrial Revolution. What was initially feared for its negative consequences on society has emerged to be the culture of ‘Technological Utopianism’. Whether the technology boom can actually help realise this utopian environment or not, it sure has come to address many major issues across industries. Industrialization has been marked by the coming together of two advancements, telecommunication and Information Technology, for bridging the technology gap between developed and the developing world. These powerhouses of global economy have been greatly accepted into the healthcare industry to aid in cure delivery, while paralleling the dynamic achievements made in medical sciences. As a form of Information and Communication Technologies (ICT), Telemedicine and mobile health are being largely employed across the globe to bridge the urban rural disparity in receiving care services. Telemedicine is best suited for nations like Africa and India, which have large populations in rural areas, devoid of quality care services and separated by great distances. Yet the adoption of these technologies is in its infancy. The industry as a whole needs to take the next step forward from the numerous pilot programs now underway to finding means of encouraging widespread roll out of Telemedicine and mHealth. The increasing use of internet and mobile phones across the globe, two of the basic requirements of Telemedicine, provides the industry ample impetus to advance this approach of care to a higher level. Improvements and advancements in telecommunication infrastructure and technology, the advent of high speed internet, improved connectivity, increased computer literacy and reduction in telecom service cost will further drive the industry. Furthermore, better privacy and security of confidential patient data and standardization of regulatory policies will form the pillars to remote provision of care services. With so much interest being induced in this emerging area of healthcare, hopefully Telemedicine will transform itself into a self-sustaining economic environment. This congress, featuring the pioneers and innovators in the field of Telemedicine, was a platform for ideas and experiences to open into opportunities for immense growth and development in this area of healthcare that has already shown great potential and promise. I would like to congratulate Rajendra Pratap Gupta from the Telemedicine Society of India for organizing an event of this magnitude and coming out with India’s First Telehealth Report
  • 5. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 3Disclaimer Telemedicine Society of India has exercised professional care and diligence in collection and processing of the information in this report. However, the data used in the preparation of this report (and on which the report is based) was provided by third-party sources. This report is intended to be of general interest only and does not constitute professional advice. Telemedicine Society of India makes no representations or warranties about the accuracy of the data in this report. Telemedicine Society of India is not liable to any user of this report or to any other person or entity for any inaccuracy of information contained in this report or for any errors or omissions in its content, regardless of the cause of such inaccuracy, error or omission. The quotations/views expressed in this report are those of the Industry leaders/speakers and do not necessarily represent views of Telemedicine Society of India. Furthermore, to the extent permitted by law, Telemedicine Society of India, its members, employees and agents accept no liability and disclaim all responsibility for the consequences of you or anyone else acting, or refraining from acting, in relying upon the information contained in this report or for any decision based on it, or for any consequential, special, incidental or punitive damages to any person or entity for any matter relating to this report even if advised of the possibility of such damages. © Telemedicine Society of India . Please do not copy or reproduce in whole or part thereof, the contents of this report without the written permission from chairman@telemedicinecongress.com For additional copies , please write to chairman@telemedicinecongress.com
  • 6. 4 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Executive Summary Despite a steady increase in the number of medical establishments and improvement in India’s healthcare infrastructure, much remains to be accomplished. There still remains a severe shortage of sub centres, primary health centres, and community health centres. While Telemedicine offers great opportunities in general, it could be even more beneficial for underserved and developing countries like India, where access to basic care is of primary concern. One of the biggest opportunities Telemedicine presents is increased access to health care. Providing populations in these underserved countries with the means to access health care has the potential to help meet previously unmet needs and positively impact health services. Telemedicine applications have successfully improved the quality and accessibility to medical care by allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically developed countries. They can provide efficient means for accessing tertiary care advice in underserved areas. By increasing the accessibility of medical care, Telemedicine can enable patients to seek treatment earlier and adhere better to their prescribed treatments, and improve the quality of life for patients with chronic conditions. Indian Telemedicine has come a long way since India's first Telemedicine centre at Apollo Aragonda Hospital was inaugurated in 2000. With its large medical and IT manpower and expertise in these areas, India holds great promise and has emerged as a leader in the field of Telemedicine. Key growth drivers include low cost of Telemedicine and wide reach over satellite or fiber optic bandwidth, lack of healthcare facilities in far-off regions, reduced technology cost and availability of qualified technical personnel, shortage of qualified medical professionals, and growth of ICT as a sector Although there are many factors that are encouraging the adoption of Telemedicine as a medium of healthcare service, there are few challenges as well faced by the industry. Issues such as absence of global regulatory framework, lack of basic IT infrastructure, reimbursement policies, and legal constraints hinder the growth of the Telemedicine market. Lack of common standards and classification could pose a challenge to the growth of this market.
  • 7. 5 Telemedicon 2011 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Telemedicine Society of India organized the 7th International Telemedicine Congress, Telemedicon’11 from 11-13th November at Hotel Westin in Mumbai. Telemedicon’11 was the ‘Biggest Healthcare Congress that has ever happened in India’. The event had an overwhelming response from one and all, which can be judged from the fact that all the exhibitor space was sold out weeks before the congress. The organizing committee members had to stop the registration process few days before the congress. Over 500 delegates from over 20 countries participated in the Telemedicine congress event held at Hotel Westin, Mumbai in India. Distinguished guests/speakers like Mr. Aneesh Chopra, CTO and Assistant to the President of USA; Shri Sachin Pilot, Hon’ble Minster of State for IT, Government of India; Dr. Prathap Reddy, Chairman, Apollo Hospitals Group; Shri Shankar Aggarwal, Additional Secretary, DIT, Government of India; Lord Nigel Crisp, Dr. Dale Alverson and a host of global healthcare leaders made this event a memorable one, and one of the biggest and most successful events in the Healthcare Industry. The entire Telemedicine ecosystem (telecom operators, telecom equipment manufacturers, mobile handset manufacturers, software vendors, policy makers, healthcare professionals) was present under one roof. Telemedicon’11 has become an iconic conference in many ways as it has also launched the Continua Health Alliance on 13thNovember 2011, followed by an interoperability workshop, for the first time in India. About 40 Exhibition stalls were organized by the top players in Telemedicine to demonstrate their products/services.
  • 8. Telehealth Report - 2011 In the current environment of Ÿ shortage of healthcare professionals and greater incidence of chronic conditions, and rising healthcare costs, are driving the need to develop tools and solutions to improve healthcare delivery. One such tool is the electronic exchange of medical information, which is commonly referred to as Health Information Technology (“Health IT”). Health IT plays a key role in digitizing and transmitting health information electronically that can improve patient outcomes. Health IT processes can also include: ŸUse of electronic health records by patients, physicians, insurers, hospitals and clinics ŸHealth information exchange across industries and geographies ŸUse of electronic health information to detect trends in population and public health ŸTransmission of medication refills and a patient’s prescription history. A key part of Health IT is increasing the frequency and use of technology-driven remote monitoring and consultation to treat patients. This area of Health IT is commonly referred to as “Telemedicine.” There is no universally accepted definition of Telemedicine.However, the American Telemedicine Association (ATA) defines the term as follows : 6 Telemedicine Concept with proceedings of International Telemedicine Congress - 2011 What is Telemedicine? “Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status” It is a broad term within Health Information Technology that encompasses methods for electronically transmitting medical information. These methods can include store-and-forward technology for documents and images, remote monitoring of a patient’s vital signs, secure messaging, e-mail exchange of data, alerts and reminders between physicians and patients, and the ability to observe, diagnose and recommend treatment via videoconference. Telemedicine can eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. Closely associated with Telemedicine is the term ‘telehealth,’ with the former restricted to service delivery by physicians only, and the latter signifying services provided by health professionals in general, (including nurses, pharmacists, and others). Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of Telemedicine. Major areas of Telemedicine include Teleradiology, Teleconsulting, Telemonitoring, & Telesurgery Ÿ Teleradiology, is the transmission of radiological patient images, such as x-rays, CTs, and MRIs, from one location to another, for the purposes of sharing studies with other radiologists and physicians. Teleradiology is a growth technology given that imaging procedures are growing approximately 15% annually against an increase of only 2% in the Radiologist population Ÿ Teleconsulting, is using Telemedicine for medical consultation. Ÿ Telemonitoring, can be defined as the use of information technology to monitor patients at a distance. Ÿ Telesurgery, (also known as remote surgery) is the capability for a doctor to perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence.
  • 9. Telehealth Report - 2011 mHealth mHealth is a new area emerging within the field of Telemedicine. mHealth or mobile health is a term used in reference to using mobile communication devices, such as mobile phones and PDAs, for health services and information. Nigel Crisp, Former CEO of NHS & Member, House of Lords mHealth applications include the use of mobile devices in collecting community and clinical health data, delivery of healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vital signs and direct provision of care. Products and Service Offerings There are multiple industries that are involved in developing various applications of Telemedicine, including IT vendors, medical device manufacturers, pharmacies, hospitals, nursing homes, and venture capitalists. Accordingly, there are numerous products and services comprising Telemedicine. Products : Many medical devices capable of collecting and electronically transmitting information can be digitized to be used in Telemedicine applications. These include blood gluc ose meters, pulse oximeters, blood pressure cuffs, spirometers, CT scanners, and MRI machines. Some of these devices are targeted towards home healthcare and the needs of patients interested in closely monitoring their health status, while others facilitate the exchange of information between hospitals, clinics and physicians. Services : The use of medical products with electronic exchange capabilities allows for the provision of a wide range of Telemedicine-related services. These include st ore-and-forward technology for documents and images, remote monitoring of a patient’s vital signs, secure messaging, e-mail exchange of data, alerts and reminders between physicians and patients, and having a specialist remotely available by videoconference to observe and diagnose a patient’s condition and recommend treatment. Electronic exchange of prescription information between physicians, pharmacies and consumers is an additional service. Other Telemedicine services include transmitting information to alert communities about pandemics, and other widespread health threats. Evolution of Telemedicine Due to the recent advances in ICT, interest in Telemedicine has increased in the last few years. The concept is not new. The first reference of the subject is probably the famous “Radio Doctor” cover image of the 1924 Radion News Magazine. One of the first Telemedicine applications reported in the scientific literature was the project for transmission of radiologic images by telephone between West Chester and Philadelphia, Pennsylvania, covering a distance of 24 miles. NASA used Telemedicine in the 1960s as a way to monitor astronaut health on space missions. Today, it’s used to electronically exchange medical information among patients, clients and health providers, creating greater access to medical evaluation and improving patient care. In the 1970s, the number of Telemedicine projects started to grow and the first real-time applications were mentioned. The STARPAHC Project tried to introduce Telemedicine in the rural Papago Indian Reservation in Arizona. Throughout the 1980s, Telemedicine specialty specific applications started to emerge, for example telepathology, which was first mentioned in 1986. The field of radiology saw the 7 “In UK, National Health Service (NHS) Direct started free health advice service over telephone. It has over six million subscribers, over 10% of the Country’s population.” Telemedicine Concept with proceedings of International Telemedicine Congress - 2011 Health IT Telemedicine mHealth Chart 1: Health IT vs. Telemedicine vs. mHealth
  • 10. 8 development of the first standard on digital medical imaging which culminated in the release of the DICOM specifications in 1992. The number of Telemedicine applications started to grow rapidly in the 1990s due to the availability of internet, affordable computers and digital imaging solution. The lat est technical breakthrough in Telemedicine was probably the first transatlantic robotic operation which was performed in 2001 by a surgeon in New York on a patient in Strasbourg. At present, electronic medical data, such as high resolution images and live video, are transferred through a v ariety of t elecommunication technologies, from fiber optics and satellites, to a simple telephone line. A growing number of medical specialties rely on Telemedicine to serve patients in areas such as adult rehabilitation, dermatology, emergency services, home healthcare, nephrology, pathology, paediatrics, perinatology, primary care, psychiatry, and radiology. Current Deployment Scenario In 2010, World Health Organization (WHO) conducted a survey to obtain an impression of the current state of Telemedicine service provision as well as four of the most popular and established areas of Telemedicine. 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), ‘informal’ (services not part of an organized program) or ‘no stage provided’ (services not part of any platform). The survey examined four fields of Telemedicine : 1.Tele -radiology: 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. 2.Tele-pathology: Use of ICT to transmit digitized pathological results (e.g. microscopic images of cells) for the purpose of interpretation and/or consultation Telemedicine Concept Telemedicine The idea of performing medical examinations and evaluations through the telecommunication network is not new. Shortly after the invention of the telephone, attempts were made to transmit heart and lung sounds to a trained expert who could assess the state of the organs. However, poor transmission systems made the attempts a failure. Ÿ1906 ECG Transmission: Einthoven, the father of electrocardiography, first investigated on ECG transmission over telephone lines in 1906 Ÿ1920s 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 Ÿ1924 The first exposition of Telecare: Perhaps it was the cover of "Radio News" magazine of April 1924. The article even includes a spoof electronic circuit diagram which combined all the gadgets of the day into this latest marvel Ÿ1955 Telepsychiatry: The Nebraska Psychiatric Institute was one of the first facilities in the country to have closed-circuit television in 1955. In 1971, the Nebraska Medical Centre was linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns Ÿ1967 Massachussetts 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 travellers Ÿ1970s 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 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011
  • 11. Telehealth Report - 2011 International Telemedicine Congress - 2011 Telemedicine Concept with proceedings of 3.Tele-dermatology: Use of ICT to transmit medical information concerning skin conditions (e.g. tumours of skin) for the purpose of interpretation and/ or consultation. 4.Tele-psychiatry: Use of ICT for psychiatric evaluations and / or consultation via video and telephone. Table 1: Teleradiology – Most developed Service areas in Telemedicine Established Pilot Informal No Stage Provided Total Teleradiology 33% 20% 7% 2% 62% Telepathology 17% 11% 9% 4% 41% Teledermatology 16% 12% 7% 3% 38% Telepsychiatry 13% 5% 5% 1% 24% Tele-radiology is currently the most developed Telemedicine service area globally, with 62% of responding countries offering some form of service and 33% of countries having an established service (Table 1). While the proportion of countries with any form of service ranged from almost 41% for teledermatology and telepathology, to 24% for telepsychiatry, the proportion of countries with established services in those three areas was comparable at approximately 15%. “Telemedicine has done well, but the difference is not visible to the audience. In order to make the difference visible, we need to bring examples of real health and economic benefits that Telemedicine provides” Nigel Crisp Former CEO of NHS and Member, House of Lords Telemedicine in developing countries While Telemedicine offers great opportunities in general, it could be even more beneficial for underserved and developing countries where access to basic care is of primary concern. One of the biggest opportunities Telemedicine presents is increased access to health care. Providing populations in these underserved countries with the means to access health care has the potential to help meet previously unmet needs and positively impact health services. Telemedicine applications have successfully improved the quality, and accessibility to medical care by allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically developed countries. They can provide efficient means for accessing tertiary care advice in underserved areas. By increasing the accessibility of medical care, Telemedicine can enable patients to seek treatment earlier and adhere better to their prescribed treatments, and improve the quality of life for patients with chronic conditions. Telemedicine has been advocated in situations wherein the health professional on duty has little or no access to expert help, with need to offer remote physician access to otherwise unavailable specialist opinions, thereby providing reassurance to both doctors and patients. Telemedicine programs have been shown to directly and indirectly decrease the number of referrals to off-site facilities and reduce the need for patient transfers. Remote care and diagnosis via Telemedicine in less-economically developed countries thus benefits both patients and the health care system by reducing the distance travelled for specialist care and the related expenses, time, and stress. Furthermore, Telemedicine programs have the potential to motivate rural practitioners to remain in rural practice through augmentation of professional support and opportunities for continuing professional development. 9
  • 12. Telehealth Report - 2011 With progress in technology, the expansion of Telemedicine in developing countries is promising, one factor being the falling costs of ICTs. Other factors include increasing computing speeds, options for high-speed bandwidth and the falling costs of digital storage. Already basic store-and-forward e-mail-based Telemedicine requires minimal investment in hardware and software where network connectivity is available, and allows for detailed exchanges by enabling the transfer of images as attachments, making it an effective solution for low-resource settings. The growing development of Internet-based conferencing (particularly through no-cost software) increases the accessibility and portability of conferencing and counters the need for expensive video conferencing equipment that may be limited by availability. Low bandwidth, Internet-based Telemedicine (e.g., store and forward, e-mail- based consultations) has also proven to be a cost-effective technology that can efficiently and effectively pre-screen patients living in remote areas. By enhancing the information communication technology infrastructure and developing better communication facilities, Telemedicine can also add to the better management of scarce medical resources and day-to-day activities in the developing world. What is holding Telemedicine in developing countries? Barriers in realizing true potential Infrastructure in developing countries is largely insufficient to utilize the most current Internet technologies. This lack and inadequate access to computing are barriers to Telemedicine uptake for many developing countries. At the most fundamental level, the variability of electric power supplies, widespread unavailability of internet connectivity beyond large cities, and information and communication equipment that is not suitable for tropical climates impose limitations on where Telemedicine can be implemented. Unreliable connectivity, computer viruses, and limited bandwidth continue to present challenges when and where Internet access is available. Internet congestion can lead to delayed imaging; poor image resolution may limit the efficacy of remote diagnosis; and slow bandwidth can prohibit the use of real-time videoconferencing. Even when basic infrastructure is in place, widespread interoperability standards for software are lacking and equipment or computer system failure remains an ever-present possibility. Financial cost also poses both a real and perceived barrier to the application and adoption of Telemedicine in developing countries. Equipment, transport, maintenance, and training costs of local staff can be daunting for countries with little income or limited funding for the implementation and maintenance of Telemedicine initiatives. Moreover, convincing evidence to support the overall cost-effectiveness of particular Telemedicine strategies may be weak, while the economic implications of such strategies in different settings may not yet be known. Local skills, knowledge, and resources may also limit the application of Telemedicine in developing countries. A lack of computer literate workers with expertise in managing computer services, combined with the lengthy process required to master computer-based peripheral medical instruments, can hinder uptake. While there may be a demand for distance learning, meeting local educational needs can be difficult due to differences in the diagnostic and therapeutic resources available, as well as the literacy and language skills across multiple sites. Moreover, while Telemedicine may enhance expert diagnosis, treatment options available are constrained by logistical challenges, including the training of local medical personnel, availability of medical equipment and supplies, and getting medicines to patients. Socio-cultural differences between sites can limit the pertinence of Telemedicine collaborations in the developing world and challenge cultural perspectives related to health and wellness. A major contributing factor to Telemedicine failure is the oversight of incompatible cultural subsystems that prevent the transfer of knowledge from one cultural context to another. Medical professionals in the industrialized world may be unfamiliar with the available facilities and alternative management strategies in remote areas and vice versa. Telemedicine, therefore, risks the exchange of inappropriate or inadequate medical information. Without a good understanding of the local context, it may be difficult to integrate Telemedicine in a useful way. 10 Telemedicine Concept with proceedings of International Telemedicine Congress - 2011
  • 13. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Lack of information available regarding legal policies, guidelines, or minimum standards concerning the use of Telemedicine in the clinical context can also prevent the adoption of such technologies. Cross-border legalities are a concern for developing countries that use Telemedicine services to connect with health professionals from more than one country. An overall lack of evaluation data, trials, and published results concerning Telemedicine initiatives in developing countries has limited the amount of evidence on the impact and effectiveness of Telemedicine. Complete evaluation is vital to systematically document best practices and lessons learnt from country-specific Telemedicine networks. Such evaluations will show which networks demonstrably alter health outcomes, prove to be cost-effective and are sustainable. These can then provide a model for other countries to adapt in their own contexts. Critical success factors include; clear program goals, garnering government and institutional support, adapting existing user-friendly interfaces, determining accessibility and connectivity constraints, implementing standards and protocols, and disseminating evaluation findings. Where can Telemedicine help? Application The healthcare-at-a-distance concept has been adopted to overcome distance barriers and improve access to healthcare services. Telemedicine is being applied to enable: Remote consultation: With Telemedicine, rural areas benefit from the same specialized services availed in urban areas. With the help of telecommunication and the internet, the technology has also been used to deliver care services to workers at oil rigs, passengers on board public transport, patients in transit, for medical tourism, and correctional systems. Home care: This application of Telemedicine has been driven by the rise in chronic conditions, aging populations, scarcity of hospital streambeds, and the current global focus of empowering patients with their own health. In support of Telemedicine technology, the delivery of care has evolved to include connected care; a care model that exploits the use of technology to provide healthcare remotely. Telemedicine is between provider and recipient, and forms a medium by which information is transmitted. This is facilitated by two basic approaches that are applied in various scenarios: 1. Real Time (synchronous), when the exchange of information is immediate, and both the provider and recipient are present simultaneously at each of their ends. An example of the synchronous type is the usage of video conferencing for Telemedicine application. 2. Store and Forward (asynchronous), where the information is acquired and stored in a particular format before it is sent for expert consultation, as in the case of using e-mail for exchange of information. The clinical applications of Telemedicine can also be categorized according to the different levels of technology maturity. Mature: The most mature applications of Telemedicine are in the areas of teleradiology and telepathology. The primary reason for these disciplines of medicine to adopt Telemedicine is the similarity between the two. It is a known fact that radiologists and pathologists rely extensively on imaging technology rather than direct contact to diagnose a condition. Hence, the practice of diagnoses through Telemedicine would not substantially differ from conventional mode. This is one of the most prominent reasons as to why radiologists and pathologists were the earliest adopters of this technology. Maturing: Maturing applications include telepsychiatry, teledermatology, telecardiology and teleophthalamology. Although there has been significant research interest in these areas, they are yet to receive institutional and professional acceptance globally, as there is a need for technology development, testing and dissemination, clinical guidelines and standards. 11 Telemedicine Concept
  • 14. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Emerging: The emerging applications have been telesurgery, telepediatrics and emergency medicine. Telesurgery has been making steady progress in the areas of remote surgery and teleconsultatative processes in view of advancements made in robotics and related technologies, as well as broadband. This arm of Telemedicine has been researched for telemonitoring (surgical instructions), and teleproctoring (overseeing a surgical procedure). Majority of research and the development in telepediatrics is focused on treating children with chronic illness and special needs. School based telepediatric services for underprivileged children is another area that has shown potential for mainstream application. How can Telemedicine help? Rationale There are several benefits that can be realized by an increased use of Telemedicine as also there are multiple factors driving the need for Telemedicine. Benefits can range from increased compliance in taking medications, to improved healthcare delivery in rural and underserved areas, to improved delivery of healthcare services outside hospitals and clinics, and better utilization of healthcare professionals. Manage chronic diseases effectively: Chronic conditions such as diabetes, congestive heart failure, and obstructive pulmonary disease, require long-term treatment and use of multiple specialists, all of which significantly increase costs. Widespread Telemedicine adoption allows vital sign information and monitoring to be gathered frequently (instead of only during periodic physician visits). Messages can then be simultaneously transmitted to the treatment team, allowing for possible early intervention (a physician or hospital visit) if a patient’s condition deteriorates. Extend reach to underserved/rural communities: Many regions of the world (both urban and rural) do not have a full range of healthcare services available. The presence of Telemedicine services in rural areas has been shown to improve care by decreasing transportation costs, more efficiently deploying healthcare professionals and specialists, and offering timely healthcare delivery without the obstacles presented by lakes, forests and mountains. Address shortages of healthcare professionals: Telemedicine services such as videoconferencing and remote consultations, better utilize current staff, whether at a hospital, physician’s office, or via home-care. The availability of Telemedicine technologies and procedures can also allevia te potential shortages of healthcare professionals by enabling remote consultations by physicians and nurses for patients located in other states or countries. Improve competitiveness of industry by controlling healthcare costs: With rising healthcare costs, Telemedicine can provide a tool for companies and insurers to better control and manage healthcare spending by enabling greater use of remote monitoring of a patient’s condition to minimize the need for acute care intervention, and more efficient deployment of healthcare professionals. Empower patients regarding their own health: Raising the responsibility level of patients to take their medicines and report basic health metrics to their physician by using Telemedicine represents an opportunity for patients and caregivers to play a greater role in their own care. Improve care of elderly, home-bound, and physically challenged patients: Use of Telemedicine to reduce the frequency of visits to physician offices and hospital emergency rooms can potentially lead to greater convenience and compliance for elderly and home-based patients. Improve community and population health: Electronic sharing of image s and video consults, a component of Telemedicine, permits easier exchange of information between public health services about a rare or unusual health condition, better measure chronic diseases in a population, or address a public health crisis. Telemedicine Concept 12
  • 15. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Reduce deaths, injuries, and infections: Increased use of Telemedicine across all settings could reduce the incidence of adverse events caused by treatment and medication errors arising from piece-meal or inaccurate patient information, leading to more consistent patient treatment by limiting the number of hospital visits and reducing exposure to illness from other patients. In addition, electronic prescribing can help reduce errors in dispensing medicines by eliminating the need to decipher handwritten prescriptions. Global Telemedicine market The global Telemedicine industry has been growing remarkably and expanding virtually across all the medical areas for the past few years. The global market for Telemedicine was valued at USD 9.8 billion in 2010, and it is expected to grow at a CAGR of 18.6% to reach USD 23 billion by 2015. The global telehospitals/clinics market in 2009 was USD 5.6 billion and accounted for approximately 71% of the total Telemedicine market. This sector is valued at USD 6.9 billion in 2010 and is expected to reach USD 15 billion in 2015, at a CAGR of 16.8%. The telehome mark et, which represented approximately 29% of the Telemedicine market in 2009, is expected to contribute 34.7% by 2015. This segment was valued at nearly USD 2.9 billion in 2010 and is expected to reach USD 7.9 billion in 2015 at a CAGR of 22.5%. One of the key factors contributing to this market growth is federal grants offered in the USA. The global Telemedicine market has also been witnessing an increase in strategic partnerships. Healthcare o rga n i zat i o n s a re a d o p t i n g Telemedicine technologies to cater to the demand for healthcare services. Other key growth drivers include shortage of health professionals, ageing population, availability of application service provider model, and affordable broadband internet access. Growth prospects of the Telemedicine market vary according to geographies. USA and Europe dominate the world Telemedicine market. USA has witnessed deployment of numerous federal grants during the past few years, which has aided in the excessive growth of the Telemedicine market in the country. Europe, on the other hand, has been witnessing a strong demand for Telemedicine products due to the rise in aging population and enhanced requirements for home treatments. Asia is the fastest growing region. It exhibits huge growth potential in the coming years as Telemedicine demand in this region will be driven by rising healthcare costs. There is a substantial rise in demand for Telemedicine in China and India. As governments and private players have stepped into the industry across most of the geographical locations, the future prospects of the market show immense opportunities to tap into. Although there are many factors that are encouraging, the adoption of Telemedicine as a medium of healthcare service, there are few challenges as well faced by the industry. Issues such as absence of global regulatory framework, lack of basic IT infrastructure, reimbursement policies, and legal constraints hinder the growth of the Telemedicine market. Lack of common standards and classification could pose a challenge to the growth of this market. Telemedicine Concept CAGR 18.6% (2010-2015 ) $Bn 25 20 15 10 5 2009 A 2010 A 2015 E Telehospitals / clinics Telehome 13
  • 16. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 As Telemedicine has the potential to improve both the quality and the access to health care regardless of the geography; the rural market is driving the incessant growth of the Telemedicine market. Without Telemedicine, access to primary care services would remain strained or nearly impossible for numerous rural patients. In the coming years, Telemedicine will not only assuage the inaccessibility that rural practitioners and patients experience, but it will also broaden the range of services to the rural residents. Other trends observed globally include adoption of 3G and High Speed Package Access (HSPA), increasing use of wireless and web-based services, integration of various devices such as patient alert devices and vital signs recording devices, and hospitals’ integrated approach to healthcare delivery. Case Studies Mobile phones for health Application Area : Remote monitoring In 2005, engineers at Loughborough University developed a mobile phone health monitoring system to monitor diabetes and other diseases. The system allows doctors to use mobile phone networks to monitor up to four key medical signals (electrocardiogram heart signal, blood pressure, levels of blood glucose, and oxygen saturation levels) from patients who are on the move. Engineers from the UK and India are working to ‘miniaturize the system’ so that sensors are small enough to be carried by patients while procuring the necessary biomedical data. In Britain, the solution will be used to improve healthcare delivery, while in India it will connect ‘centres of excellence’ to hospitals and clinics in more remote areas. Over the next three years, clinical trials will occur in both the UK and India. Ÿ UK-based Loughborough University's engineers entered into a partnership with India to develop a unique mobile phone health monitoring system. Ÿ The system, which was first unveiled in 2005, uses a mobile phone to transmit a person's vital signs, including the complex electrocardiogram (ECG) heart signal, to a hospital or clinic anywhere in the world. Ÿ Presently, the system can transfer the signals pertaining to the ECG, blood pressure, oxygen saturation and blood glucose level. Ÿ IIT, Delhi, the All India Institute of Medical Sciences and Aligarh Muslim University and London's Kingston University joined hands to further develop the system. Ÿ The research team is aiming to miniaturize the system by designing sensors and mini-processors that are small enough to be carried by patients, and at the same time procure biomedical data. The network of sensors would be linked through a modem to mobile networks and the Internet, and to a hospital computer. Then, doctors can use this device to remotely monitor patients suffering from chronic diseases, like heart disease and diabetes. Ÿ The clinical trials of the system are going on in the UK and India. Support to Promote Maternal and Newborn Health The aim of the Telemedicine Support to Promote Maternal and Newborn Health in Remote Provinces of Mongolia project is to reduce infant and maternal mortality while addressing the gap between urban and rural healthcare services. The project started in September 2007 and continued till December Telemedicine Concept 14
  • 17. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 2010. Telemedicine services supported Aimags (province), with high-risk pregnancy consultations, prenatal ultrasound diagnostics, foetal monitoring and screening for cervical abnormalities using colposcopy. The services provided by the project were particularly important for women in remote rural regions who do not have the funding to travel for expert opinion. A total of 297 doctors, nurses and midwives were trained for this program between March and December 2009. A total of 598 cases were referred in 2009. Of these, 64% were obstetrical, 21% were gynaecological pathology and 15% were neonatal pathology. Only 36 of these cases were referred to Ulaanbaatar for treatment following the diagnosis, substantially saving the resources of rural residents that would otherwise have gone towards travel expenses. Opportune Breast Cancer Screening and Diagnosis Program In 2006, breast cancer became the leading cause of death among Mexican women between the age groups of 50 to 69. The Opportune Breast Cancer Screening and Diagnosis Program (OBCSDP) was meant to transcend economic and personnel barriers through the innovative deployment of ICTs. Aimed to reduce the breast cancer mortality rate in women, the program increased the national screening rates from 7.2% in 2007 to 21.6% by 2012. The Telemedicine network has a goal to screen 1.3 million women in a 30 month period between May 2010 and December 2012. With over 34 million Mexican pesos (USD 2.8 million) of seed funding from the federal and state governments as well as not-for-profit groups, 30 screening sites in 11 states were linked by internet to two interpretation centers where results of the screenings could be viewed by radiologists. Due to challenges with internet connectivity in rural areas of Mexico, many Mexican communities lack the necessary bandwidth for internet protocol-based image transmission (necessary to transmit mammograms). To overcome this challenge, CDs were used for patient data transfer and long-term data (backup) storage. (Each carried four patient images (a full mammography) and up to four patient mammograms). CDs were privately or commercially couriered to the closest interpretation centre. However, results with this method took up to three weeks to be returned to individuals. Text to Change Sponsoring Organization and Partners: Celtel, AIDs Information Centre (AIC), Merck, and the Dutch Ministry of Foreign Affairs. Text to Change (TTC) program provided HIV/AIDS awareness via SMS based quiz to 15,000 mobile phone subscribers during three months in Uganda. TTC was founded with the goal of improving health education through the use of text messaging, which holds the advantages of anonymity and strong uptake among the population. Partnering with the mobile carrier Celtel and the local NGO AIDS Information Centre (AIC), TTC conducted a pilot program from February till April 2008 in the Mbarra region of Uganda, with the objective of increasing public knowledge of and changing behaviour regarding AIDS. The program aimed to encourage citizens to seek voluntary testing and counselling for HIV/AIDS. Free airtime was offered to users to encourage participation in the program. This was determined to be a powerful incentive since users could exchange the airtime with other subscribers as a type of currency. The quiz was interactive. When participants gave a wrong answer they received an SMS with the correct answer from the cell phone provider. The uptake rate of the survey was 17.4%. The quiz focused on two specific public health areas: Ÿ General knowledge about HIV transmission, and Ÿ Benefits of voluntary testing and counselling. 15 Telemedicine Concept
  • 18. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 At the end of the quiz, a final SMS was sent to motivate participants to go for voluntary testing and counselling at the local health centre. Those who went to the centre were asked a final question: Was this the first time they had an HIV test? After testing, participants were requested to leave their mobile phone number so that post-test counselling could be arranged. For the people who came to the health centres through TTC, HIV testing and counselling was free of charge. Initial grants from Merck, the US pharmaceutical company and the Dutch Ministry of Foreign Affairs supported the program launch. Bringing critical pediatric care to a rural hospital Intel announced a comprehensive set of digital inclusion projects aimed at improving education, healthcare and economic development for Nigeria's 140 million people in 2007. With the support of the Federal Ministry of Health, Intel launched a pilot Telemedicine project that brings critical pediatric care to a rural hospital serving a region of 4.5 million people. They are now able to consult in real time with pediatric and surgical specialists in Abuja through the new Telemedicine system, which features video conferencing and high-speed broadband connections through Wimax (a long-range wireless technology). The pilot makes it possible for physicians to shorten both time and distance in getting to patients to treat them. The system connects one of Nigeria's leading medical institutions, the National Hospital in Abuja with the Federal Medical Centre in Bida, a rural 200-bed medical facility. Till now, patients who needed referrals from Bida were forced to travel at least 250 kilometres to reach specialists, a trip most could not afford. Bida has an acute need for care from pediatric medical specialists. In the project's first phase, a foetal monitoring capability will permit pediatrician to remotely and more quickly consult with medical staff and examine expectant mothers to monitor the progress of their pregnancies. Intel is also training medical practitioners and technical specialists at both hospitals to use the new technology tool. Telemedicine Concept 16
  • 19. Telemedicine in India The healthcare model in India is a three tier system. At the first tier are the primary centres and sub-centres that provide services at the village level. The secondary level comprises healthcare facilities located at the district level, which includes district hospitals, private clinics and small nursing homes with limited equipment and expertise. The third tier or tertiary level healthcare settings are through medical college hospitals, specialty, and super specialty private chains of hospitals generally located in urban areas. Besides, there are a few advanced medical institutes of national importance, having clinical, teaching and research facilities in various super specialties. Primary level includes Primary Healthcare Centres (PHC’s) and sub-centres at the village level equipped with a practitioner and facilities to provide first-aid or basic medical check-ups. However, many centres lack qualified practitioners, adequate medical supply, specialty solutions, connectivity and medical beds, etc. Secondary level includes District level hospitals, small private clinics and nursing homes with small equipment and facilities limited to providing basic medical diagnosis. However, In India they too lack specialty treatment facilities, high-end medical equipment and adequate number of beds. 17 Health care model in India Primary centers and sub-centers that provide services at the village level Healthcare facilities located at the district level including district hospitals, private clinics & small nursing homes with limited equipment and expertise Medical college hospitals, specialty, and super specialty private chains of hospitals generally located in urban areas Tier-1 Tier-2 Tier-3 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011
  • 20. 18 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Chart 4: Public spending as a % of total healthcare spend, 2007 Tertiary level includes medical colleges, big private chains of hospitals and corporate hospitals situated in large urban areas. Facilities include high-end medical equipment, well qualified medical staff, etc. These institutions, however, service a small segment of the vast population of the country. Despite a steady increase in the number of medical establishments and improvement in India’s healthcare infrastructure, much remains to be accomplished. There still remains a severe shortage of sub centres, primary health centres, and community health centres. Lack of adequate healthcare is also reflected in the low density of healthcare personnel. India does not have a national health insurance policy or any other national healthcare guarantee program for its citizens. The existing three tier health care system is highly inadequate in providing quality healthcare services due to India’s increasing population and the growing demand for healthcare services. Growth in physical infrastructure i.e., healthcare facilities and hospitals is not sufficient to meet the current demand. The poor state of healthcare system in India may also be attributed to the lack of government funding on healthcare initiatives. As estimates reveal, per capita spending on healthcare by the Indian Government is far below international recommendations. The healthcare spend, when compared on the basis of public-private contribution, also depicts a skewed picture. Private sector contribution to the healthcare at approximately 74% is amongst the highest in the world. Public spending, on the other hand, is amongst the lowest in the world and is approximately 26% points lower than the global average. Indian Healthcare Market The Indian healthcare sector represented a USD 40 billion industry in 2009. Hospitals accounted for approximately 50% of the market, pharma contributed 25%,diagnostics with 10%, and medical equipment accounted for roughly 15%. The industry is expected to grow to USD 79 billion by 2012 and USD 280 billion by 2020 at a CAGR of 21.5%. The Healthcare sector, in India, is at an inflection point and is poised for a healthy growth in the medium term. Healthcare spending is expected to grow to 8% of the GDP in 2012. A combination of demographic and economic factors is expected to bring increased healthcare coverage in India which is expected to drive the growth of the sector. India‘s rising population and income levels, along with a growing preference for private health services over public services, is augmenting the growth of the healthcare delivery market. Population growth and increased disposable income are expected to result in better healthcare awareness and more expenditure on healthcare. Telemedicine in India Indian healthcare spend as a % of GDP is less than half the global average Chart 3: Healthcare spending as a % of GDP, 2007 % 20 15 10 5 0 US Brazil UK China India Global Per Capita spending as compared to other Countries is also very low in India Chart 5: Per Capita Healthcare spending, 2007 USD 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 US UK Brazil China India Global Public healthcare spending in India is again half the global average, amongst the lowest in the world % 100 80 60 40 20 0 US Brazil UK China India Global Chart 6: Healthcare industry in India % 300 250 200 150 100 50 0 CAGR 21.5% (2010-2020 ) 2010 A 2012 E 2020 E
  • 21. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Healthcare expenditure (public and private) in India is expected to increase by 15%. India has the potential to add nearly 1.74 million beds by 2025 with an investment of about USD 104 billion to fulfil the unmet needs. The demand for quality healthcare in India is burgeoning and there exists a huge supply gap. An additional 1.74 million beds are needed to achieve the target of two beds per 1,000 populations by 2025. An additional 700,000 doctors will be required by 2025 to reach a ratio of one medical doctor per 1,000 individuals. To maintain the current doctor-to-nurse ratio of 2.2, an additional 1,600,000 nurses will have to be trained by 2025. Population of India is expected to increase from about 1.21 billion in 2010-2011 to 1.4 billion by 2026. In addition, an expected increase of geriatric population from current 96 million to around 168 million by 2026 represents a huge patient base and creates a market for preventive, curative and geriatric care opportunities. Households can benefit from an increase in disposable income from 14% in 2009-2010 to 26% in 2014- 2015 making healthcare more affordable. There is likely to be a marked increase in the incidence of lifestyle-related diseases, such as cardiovascular, oncology and diabetes, when compared to the communicable and infectious diseases. Growing general awareness, patient preferences and better utilization of institutionalized care is expected as a result of increase in literacy rates. Lower direct taxes, higher depreciation on medical equipment, income tax exemption for five years to hospitals in rural areas, etc. are being provided by the Government to the sector to boost it. India is also emerging as a major medical tourist destination with medical tourism market expected to reach USD 2 billion by 2012. Telemedicine – Promising Future Telemedicine can embrace modern technology to widen healthcare accessibility in rural India and can be a solution for India’s healthcare woes. A vast country like India, with a population of over 1.2 billion across 29 states and 6 Union Territories and governed by a federal system, needs affordable healthcare. “It is a fact that has not been accepted by policy makers that it is nearly impossible under the current rural infrastructure and payment terms to get good doctors to work in rural India. In addition, building healthcare facilities and maintaining them in rural India is financially unviable. So the current healthcare system will always be an ad hoc arrangement and a highly subsidized one while not being a lasting solution. Rural India needs to extensively leverage the 3G and WIMAX technology and adopt preventive care model to avoid pain, suffering and high cost of healthcare” Rajendra Pratap Gupta, Leading Global Healthcare Policy expert Telemedicine today has given the ability to the doctors to provide healthcare to the needy. It is taking modern healthcare to remote areas. Majority of diseases not requiring surgery are conducive to Telemedicine. It allows training of medical personnel across the country to provide services to the patients in remote areas. Over the last five years; both price and complexity of this technology has decreased making Telemedicine economically viable. Telemedicine, as a branch of diagnosis and treatment, should be encouraged and widely implemented to help ensure availability and accessibility of care to all areas in spite of infrastructural inefficiencies. 19 Telemedicine in India
  • 22. 20 Telemedicine is the convergence of communication technology, information technology, biomedical engineering and medical science. In India, early forms of Telemedicine used telephone and radio followed by communication through fiber optic cables. Lately, Telemedicine has evolved to utilizing video telephony, advanced diagnostic methods supported by distributed client/server applications, and telemedical devices to support medical care at homes. This evolution in Telemedicine is through satellite communication developing from ‘Point to Point System’ (one remote location connected to one main location) to ‘Point to Multi Point System’ (one remote location at a time connected to many main locations), and finally to ‘Multi Point to Multi Point System’ (several remote locations simultaneously connected to main locations in different geographical locations). Chart 7: Pillars of Telemedicine Video Conferencing District Hospital Telemedicine Specialty Hospital Panel of Doctors Chart 8: Representative Telemedicine structure Remote Location Ÿ Regional/secondary care hospitals Ÿ Rural health care services Ÿ Primary care Ÿ Consultation and diagnosis Ÿ Patient education and follow-up Ÿ Professional education Ÿ Continuing medical education Ÿ Administrative services Main Location Ÿ Regional/tertiary care hospital Ÿ Consultation Ÿ Screening and diagnosis Ÿ Monitoring Ÿ procedure guidance Ÿ Patient education & follow-up Ÿ Professional education Ÿ Continuing medical education Ÿ Administrative services Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Telemedicine in India Medical Science Communication Technology Biomedical Engineering Information Technology
  • 23. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 The Telemedicine system comprises of customized hardware and software at the “Patient” site and the “Specialist doctor” site, with diagnostic equipment like ECG, X-ray, Pathology, Microscope/Camera, etc. provided at the patient end. They are connected through a Very Small Aperture Terminal (VSAT), WIFI, and Broadband, controlled by a Network Hub Station. Through a Telemedicine system that consists of a simple computer with communication systems, the medical images and other information pertaining to the patients can be sent to the specialist doctors, either in advance or on a real time basis through the satellite link in the form of Digital Data Packets. These packets are received at the specialist centre, the images and other information are reconstructed so that the specialist doctor can study the data, perform diagnosis, interact with the patient and suggest the appropriate treatment during a Video Conference with the patient end. Telemedicine facility thus enables the specialist doctor and the patient, separated by a distance, to interact visually and talk to each other. Major components of Telemedicine include : Ÿ Telemedicine workstation Ÿ Document and radiographic film digitizer Ÿ Ultrasound device, ECG, MRI, Scanner, X-Ray Ÿ Processing unit and keyboard Ÿ Audio Module – speakers, headphones, volume and base control Ÿ Camera - lens, image sensor, pixels, resolution, illumination range, video output signal, power zoom Ÿ Microphone Ÿ Monitor – resolution, speakers, signal type, dot pitch Ÿ Central power switch, power requirements Ÿ Communication platform allowing compatibility with networks (WAN) – SW-56, ATM, ISDN, satellites, and networks (LAN) - Ethernet Ÿ Connector panel – LAN, WAN, phone network, audio and video input and output ports, radiographic film digitizer, CD-ROM, etc. Ÿ Telemedicine peripheral devices – Otoscope, Dermatoscope, Stethoscope, Ophthalmoscope, etc. Ÿ Telecommunication network architecture Ÿ Plain Old Telephone System (POTS) - Analog telephone lines Ÿ Dial-up digital telephone lines - Integrated Service Digital Networks (ISDN) and Switched-56 (SW-56) Ÿ Asynchronous Transfer Mode (ATM) Ÿ Satellite – Geo-synchronous and Low Earth Orbit (LEO) Ÿ Microwave Ÿ Coaxial Cable, Fibre Optics Ÿ Asymmetric Digital Subscriber Line (ADSL) Ÿ Various Digital Subscriber Line (xDSL) Ÿ Internet or Modem Ÿ Virtual Private Networks Ÿ Hospital and Regional Health Networks Ÿ Software Architecture Ÿ Human intervention Ÿ Physicians – General practitioners, specialists and medical students, etc. Ÿ Nurses – Registered Nurses (RN), Licensed Practical Nurses (LPN) and nursing students Ÿ Allied Health Professionals – occupational therapists, physiotherapists, etc. Ÿ Health Administrators, Educators and Researchers Ÿ Technicians Ÿ Patients and their families, informal care givers Ÿ Telehealth project Managers and site coordinators. 21 Telemedicine in India
  • 24. 22 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 mHealth mHealth, also known as Mobile health, leverages mobile devices and ICT to deliver health services and information exchange which can increase access, affordability, and quality of healthcare significantly. Telemedicine in India Today’s Technology Tomorrow’s Technology Hardware Ÿ Features suitable for basic mHealth services available on mobile phones Ÿ Mobiles can access web, download pictures, etc. Ÿ Internet speeds limit the number of applications which can be used Ÿ Most laptops, handhelds, PDAs easily access wireless networks where available Ÿ Cell phones and mobile computers become less discrete Ÿ Larger displays and Solar chargers for mobiles Software and applications Ÿ Widely available for laptop and handhelds Ÿ Availability of handsets with open architecture. Ÿ Open source software accelerate application development and reduce cost Network access Ÿ Cellular usage common in urban areas compared to rural areas Ÿ Broadband, internet access is limited in several geographies and also costly Ÿ Network transparency Ÿ Wireless networks create almost universal Internet access Standards Ÿ Policies and standards required for Broadband Ÿ Allowance of greater range of services, provider Ÿ Partnerships Services Ÿ Education/awareness programs Ÿ Medication monitoring Ÿ Data collection services Ÿ Disease tracking Ÿ Remote monitoring Ÿ More sophisticated diagnoses/consultations, e.g., Teleradiology, teleopthamology. Ÿ More effective use of healthcare workers Ÿ More ‘personal’ mHealth services Ÿ Services for travel-restricted Chart 9: Mobile technology evolution Technology advancement WIMAX availability for Pcs Open source systems Greater bandwidth IP access for standards and decisions over licensesI Better services offerings
  • 25. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 It involves the use and capitalization of a mobile phone’s core utility of voice and short messaging service (SMS), as well as more complex functionalities and applications including general packet radio service (GPRS), third and fourth generation mobile telecommunications (3G and 4G systems), global positioning system (GPS) and Bluetooth technology. As 3G swings in India with over 900 million mobile phone connections and Android phones become increasingly available, the opportunity for high value mobile enabled services is tremendous. Two industries that have already tapped into the ubiquity of mobile phones in a big way are entertainment and financial services, with applications ranging from music downloads to banking that are attracting swaths of users and investments. But mHealth has only scratched the surface in India largely because there is a lack of awareness among patients and doctors about what mHealth is and what benefit it can provide. 23 Table 2: mHealth – A win-win for all Ÿ Improved treatment, education, and illness prevention Ÿ Improved operational efficiencies, improved quality, and effectiveness of healthcare Ÿ More effective delivery of healthcare services Ÿ Improved operational efficiencies Ÿ Organizational mission closely ties to program success Ÿ Expansion or scale of program Ÿ Revenue from hardware sales Ÿ Strategic market positioning for short and long term brand and business development Ÿ Revenue from training or supporting contracts Ÿ Opportunities for placement in network expansion projects Ÿ Revenue from service fees through increased subscribers Ÿ Revenue from handset device sales Ÿ Expanded mobile subscriber base for increased revenue from other services Ÿ Revenue from application license fees Ÿ Revenue from application customization fees Ÿ Revenue from training contracts, hardware support system Ÿ Opportunity to become a standard in mHealth Ÿ Potential for add-on sales as program scales Patient: Recipient of healthcare service Caregiver: Delivering healthcare services like physicians, nurses, midwives, healthcare workers Project management: The entity responsible for direct management of the project including business and programmatic, like a government agency or independent organization Equipment provider: Generally the manufacturer of any hardware relative to the services including customer devices or network devices. May also provide training, support to operator or health care practitioner. Service provider: The mobile telephony operator Application Solutions provider: The entity providing mHealth application, either as a standalone software application or an integrated application Telemedicine in India
  • 26. 24 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Telemedicine in India Table 3: Overview of mHealth use case findings across the Healthcare Continuum ŸAccessibility of patient data; reduction in procedures and tests; fewer medical errors ŸImproved patient access to physicians; increased billable hours ŸLower administrative costs; faster service ŸImproved supply chain efficiency/accuracy; increased productivity; lower risk of compliance breaches ŸAccurate and timely feedback to patients; ease of coordinating remote providers; streamlined consultations ŸRegular patient monitoring; increased productivity; reduced travel time ŸReal-time updates of patient data; ability to offer “untethered” care outside of traditional settings ŸEase of locating specialists and services in network; lower costs with drug cost-comparison shopping; increased consumer usage of plan benefits; better management of medical expense accounts ŸIncreased accuracy and lower costs; compliance-certified apps meet regulatory requirements ŸCommunity-based retail stores use mobility to improve ACO care coordination ŸReal-time access to data to advise doctors and patients on drug therapies and associated risks ŸEnables pharmacists to interact with patients “in the aisles” with access to real-time patient data ŸMore efficient and accurate order processing; improved compliance in sample distribution; digital signature capture ŸAbility to identify and catalog worldwide epidemiologic trends ŸInteractive apps to identify appropriate care providers ŸAccurate and timely feedback of health data; rapid throughput of test results to providers ŸImproved care/lower costs through home healthcare ŸGreater emphasis on patient-centered care; reduced isolation of convalescing patients ŸIncreased knowledge of cost/benefit trade-offs ŸElectronic Health Records, Health Information Exchange ŸTelehealth/remote care ŸPatient self-registration using tablets ŸBar code scanning ŸElectronic Health Records, Health Information Exchange ŸTelehealth/remote care ŸPeripheral devices integrated into mHealth solutions ŸConsumer self-help apps ŸMobile apps replace paper-based forms; bar code scanning ŸDrug reference and drug interaction apps ŸMobile access to back-office ŸMobile CRM apps for “detail” sales representatives ŸElectronic Health Records, Health Information Exchange ŸSymptom checker ŸApps with integrated peripheral devices ŸTelehealth/remote care ŸSocial engagement-based solutions Hospitals Doctors, Nurses Insurance Companies Suppliers Pharmacies Drug and Medical Supply CRM Federal Agencies Consumers
  • 27. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 A February 2011 report authored by Pyramid Research found that more than 200 million mobile health applications are used by doctors and patients today, and more than 600 million medical apps will be available by 2012. (Source: Pyramid Research) According to a February 2011 study by Aptilon, 79 percent of physicians prefer the iPad, compared with 12 percent of doctors who prefer a Windows-based tablet and nine percent who prefer an Android device. An InfoWorld article published in May 2011 cites a study by RNCOS. The study estimates healthcare IT spending in the United States is expected to reach $40 billion in 2011. Of that, the mobile health market is estimated to be 5.3 percent of total healthcare IT spending. Projections indicate that over one third of all smartphone holders worldwide or 1.4 billion people globally, will be using mHealth solutions within the next five years, according to research2guidance. Through informal polling, Epocrates estimates up to 70 percent of medical schools are having a mobile device requirement or recommendation for medical students. The average physician can re-purpose 130 administrative hours each year by using a mHealth solution. According to Galvin Consulting, August 2011, many healthcare professionals are looking to new mobility technologies as a way to solve some of the industry’s most pressing problems. These thought leaders believe society is on the cusp of dynamic change in the way healthcare is both provided and consumed. Mobility in the general workforce is expected to increase at an unprecedented rate in the coming years, both in the United States and other countries, including India. In developing countries such as India, mHealth shows special promise in specific mHealth applications, including: Ÿ Widespread care through telemedicine and “virtual hospitals”. Ÿ Improved medical data processing as a result of direct data input into mobile devices. Ÿ Improved patient care as physicians interact directly within local communities. Ÿ Early warnings of shifting health trends, including emerging and infectious diseases, as large amounts of data from mobile devices are collected and analyzed. Ÿ Improved disaster response efforts for earthquakes, floods and other disasters as first responders use mobile devices to identify areas most in need of assistance. Over and above these benefits are improved accuracy throughout the healthcare system and earlier detection of medical issues that help to prevent expensive and serious complications later. Current state of Telemedicine in India Telemedicine practice was first initiated in Lucknow and Chennai in 1997. In Kerala, first unit of Telemedicine was formed at the Medical College, Thiruvananthapuram in 2003. Recognizing the common interest of health and community welfare, Telemedicine was promoted for the availability of quality medical services to the needy, irrespective of socio economic and geographic disparities like rural, remote, and inaccessible places. During the National Conference on Telemedicine held in Lucknow in April 2001, the participants resolved to form a scientific society dedicated to Telemedicine at national level and carry out an annual scientific event pending a formal registration. Thus the Telemedicine Society of India (TSI) was born and all the participants signed a resolution to this effect and were made the founding members. It has been a long journey for the TSI. Although the efforts had started from 1996, yet it took time to reach this position. Having survived infancy, it is now coming of age. In all developing countries, there is an acute shortage of resources in the health care sector. In emerging economies like India, there has been an 25 Telemedicine in India
  • 28. exponential and an unprecedented increase in the availability of Information and Communication Technology. ICT has provided a unique opportunity of bridging the urban rural health divide. For Telehealth to take off, it had to be embraced by all the stakeholders; the Government, private sector, public sector, entrepreneurs, etc. The first TSI meeting was held in Lucknow in 2001. Its focus was on rural medicine. Initial support from ISRO played a very vital role in the growth of Telemedicine in India. The official TSI meet took place in Bangalore in 2005 when the smooth life of TSI began. Then the annual successive meets took place in Delhi (2006), Chennai (2007), Chandigarh (2008), Pune (2009), Bhubaneshwar (2010), and Mumbai (2011). The first TSI chapter was started in 2010 in Bhubaneswar. Over a period of time, TSI has extended their services to Indian army. They set up Telemedicine units initially in the southern command and subsequently in the central command. Training programs were organized exclusively for officers. They have also pioneered in partnerships with Uganda, Mauritius, Nigeria, the Netherlands, etc. As of now, TSI has provided teleconsultations in various specialties to 29 countries in Africa, and also initiated teleconferences with many countries including Japan, US, Saudi Arabia and Hong Kong. India is beginning to make strides in the areas of Telemedicine and eHealth. Most of the Telemedicine activities are in project mode, supported by the ISRO and the Department of Information Technology and being implemented through state governments. A few corporate hospitals have developed their own Telemedicine networks, prominent among them being the Apollo Telemedicine Networking Foundation, which commenced Telemedicine operations as early as January 2000. Around 500 Telemedicine nodes are in place across the country. Telemedicine has a market size of USD 70 – 110 million in India. It is expected to grow at very high CAGR of approximately 35% over the next five years to reach USD 314 – 493 million by 2016. The full potential of the Telemedicine market could be realized with appropriate stakeholder vision and better adoption. Key growth drivers are: Ÿ Low cost and wide reach over satellite or fiber optic bandwidth Ÿ Lack of disease management framework Ÿ Lack of healthcare facilities in far-off regions Ÿ Reduced technology cost and availability of qualified technical personnel Ÿ Shortage of qualified medical professionals Ÿ Increased government focus on healthcare for all Ÿ Urban-rural divide causing disparity in medical facilities Ÿ Dedicated satellite for health communications from ISRO Ÿ Growth of Information and Communications Technology as a sector Ÿ National Telemedicine grid to connect practitioners and institutions Ÿ PPP model for development of healthcare infrastructure The key growth driver for Telemedicine is India is its technologically advanced ICT sector which is self-sufficient in meeting its needs of hardware, software, connectivity and services. Therefore, ICT technologies have the potential of making healthcare affordable for India, especially in rural India. This success can be further reinforced if these ICT technologies are integrated into existing health-care delivery systems. In the last decade, there has been active investment for development of Telemedicine in India, but considering the demographic spread, this investment is not sufficient for such a large country. The scale of Telemedicine services in India has been limited so far to medical transcription, health awareness through portals, Telemedicine and hospital management system and customer service using the internet. While globally and particularly in Africa, advanced technologies such as 3G services are used efficiently for providing healthcare solutions to remote villages, the use of communication devices such as mobile phones or conferencing solutions for Telemedicine in India has been limited. 26 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Telemedicine in India
  • 29. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 “In the next 3-5 years, I can well foresee a fight between Tablets & Smart- Phones, a fight between Windows, Apple & Android rather than a fight between a user and non-user of mHealth.” Rajendra Pratap Gupta, Leading Healthcare Policy Expert “mHealth is more relevant in India than conventional eHealth, as access to PCs, laptops and broadband is far less than access to mobile phones. India has just 12 million broadband connections, 24 million internet subscribers and 85 million PCs as compared to 881 million mobile phones.” Prof. K. Ganapathy, President of Telemedicine Society of India and President of Apollo Telemedicine Foundation Utilizing wireless to access the internet is steadily increasing and telecom operators in India see this as a growth segment. One would not like to call mHealth a killer application, but considering that health is a truly universal requirement, this would perhaps be an apt description. The ubiquitous all-pervading universally available mobile phone can now be used as a tool, and an enabler to deliver healthcare. There are unlimited opportunities and strategies for using the mobile in implementing mHealth in hospitals, insurance companies, Pharma companies, etc. With thousands of health applications, the mobile phone can soon become a hand held hospital. According to Dr. P S Ramkumar, Director of Applied Cognition Systems, “Practical mHealth will take time, although the concept is easy to sell due to large scale user familiarity with mobile phones. Although mobile communication has equipped the country with approximately 881 million phones, a recent survey has found that, of 30 Tele-Health projects only two had intersect with mobile phones while 60% used free satellite connections provided by government initiatives. The RTBI group of IITM in collaboration with LIRNEasia, Sri Lanka, National Centre for Biological Sciences, Bangalore and Department of Health and Family Welfare, Tamil Nadu, have demonstrated adoption of ordinary text based cell phones by rural health workers showing improvement in disease surveillance and response time. Apollo Telemedicine network foundation has demonstrated Telemedicine application on mobile platforms on 3G networks in collaboration with Ericsson’s Gram-Jyothi program demonstrating Tele-presentation of radiology images, ECG, etc. “It is not possible for everyone to own a computer or to use a computer for health, but smart phones comes in handy, and so, for sure, all aspects of healthcare will finally converge to mHealth” Rajendra Pratap Gupta, Leading Healthcare Policy Expert 27 Telemedicine in India Growth of Health Apps by Platform over six month period Platform Total Apps as of 2/2010 New Apps launched: /2010 – 9/2010 Total Apps as of 9/2010 Growth Apple AppStore Health Apps 4,276 2,860 7,136 66.6% Google Android Health Apps 505 791 1,296 156.6% Blackberry App World Health Apps 140 198 338 141.4%
  • 30. However, the system lacks legal clarity on the question of who is accountable for delayed data, inaccurate transmission and privacy/security loss of the data” A truly different way of patient empowerment, mHealth can bridge the urban rural health divide. With 50 mobile phones being sold every second, with an urban teledensity of 113% and a rural teledensity of 49%, India should certainly be poised to incorporate mHealth into the very fabric of its healthcare delivery system. Key stakeholders driving Telemedicine Tele medicine as a concept has multiple areas of application which are not only based on advantages key to the medical field but also help in the business end by accessing more people and reducing costs for all parties involved. This has led the various possible stakeholders in India to actively implement and promote Telemedicine. A key part of Telemedicine, m-Health or mobile driven health services is receiving the most amount of attention. This is fuelled by India’s unique mobile service cost structure combined with the huge disparate population and low cost of mobile handsets. The major stake holders in the progress of Telemedicine can be broadly classified under three categories : 1. Government and Government Bodies This includes organizations that facilitate growth of Telemedicine through policy initiatives, and financial backing. It consists of organizations such as the Ministry of Health and Family Affairs, the Department of Information Technology, Ministry of Communication and IT and the various state governments. In India, various departments have been proactive in launching initiatives and partnering with various other organizations to promote Telemedicine. Ÿ Ministry of Health and Family Welfare (MoHFW), Government of India There is a very structured and planned approach toward Telemedicine in India. This is evident from the setup of the National Task Force on Telemedicine under the chairmanship of Secretary, Union Ministry of Health and Family Welfare, incorporating members from various concerned ministries of the union government e.g. Health, Communication & Information Technology and Space; technical agencies e.g. Indian Space Research Organization, Indian Council of Medical Research, Medical Council of India, Centre for Development of Advanced Computing; academic medical institutions and corporate hospitals practicing Telemedicine actively. Ÿ State Governments A large number of state governments have shown positive support for the development and inclusion of telemedical facilities in their state. In Odisha and Uttarakhand, the secondary-level hospitals have now been linked to SGPGIMS at Lucknow for specialty consultation with the support of the governments. ISRO together with the government of Chhattisgarh has established a state-wide network linking the state government medical colleges at Raipur and Bilaspur and other premier hospitals across the country. Similarly, the Rajasthan state government has established a Telemedicine network between six state medical colleges and 32 district hospitals and six mobile vans with ISRO’s aid. The Karnataka State Telemedicine Network Project, run by an autonomous trust formed by the state government, has set up 30 nodes in collaboration with ISRO. The Punjab go vernment has also launched a Telemedicine project, with state-of-the-art facilities at the Government Medical College and Hospital to link the five polyclinics set up in the state. Many state governments, along with the department of IT, have started establishing Telemedicine networks with state specialty hospitals connected with different district and smaller health centres. Some of them are the governments of Tripura, West Bengal, Himachal Pradesh, Punjab, Tamil Nadu and Kerala. 28 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Telemedicine in India
  • 31. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Ÿ Ministry of External Affairs Projects The progress in Telemedicine is not restricted within domestic networking and resource pooling. The ministry of External affairs has initiated a SAARC Telemedicine Network project that connects one or two hospitals in each of the SAARC countries with three to four super-specialty hospitals in India. The super specialty hospitals in India include AIIMS, SGPGIMS, PGIMER at Chandigarh and the CARE Hospital at Hyderabad. 2.Technology Providers By collaborating with state governments the Department of Information Technology (DIT) and Ministry of Communication and IT (MCIT), has established a Telemedicine network of more than 100 nodes all over India. The medical network includes: 29 ŸWest Bengal for diagnosis and monitoring of tropical diseases. Ÿ Kerala and Tamil Nadu Oncology Network for facilitating cancer care. Ÿ North-eastern and Himachal Pradesh hilly states for specialty health care access. Another initiative of the ministry, the Pan-African eNetwork Project, along with Telecommunications Consultants India Ltd. (TCIL) is that of setting up a VSAT-based Telemedicine and tele-education infrastructure for African countries in 53 nations of the African Union. Ÿ Various technology providers This group includes the various companies such as Ericsson, Texas Instruments, CISCO Systems, C-DAC, Sony which provide specialized hardware and software solutions aimed at innovative telemedical services. The category also includes the various stakeholders which provide the sustaining infrastructure and connectivity support. In India some of the players so far have been ISRO, Aircel, Airtel and IBM. The contribution of these stake holders has been in terms of forging relationships that prove to be socio-economically beneficial to the country. With innovation in services and improved efficiencies in communication and support tech, these groups of stakeholders hold the key to the long term growth and commitment to Telemedicine in India. Ÿ Indian Space Research Organization (ISRO) ISRO’s pilot Telemedicine project was launched in 2001 with the aim of introducing the Telemedicine facility to the grassroots level population as a part of “proof of concept technology demonstration” program. The Telemedicine facility connects the remote District hospitals/health Centres with super specialty hospitals in cities, through the INSAT Satellites for providing expert consultation to the needy and underserved population. Telemedicine facilities are established at many remote rural district hospitals in many states and union territories of the country including Jammu & Kashmir, Andaman & Nicobar Islands, Lakshadweep Islands, and North Eastern States, etc. State level Telemedicine networks are established in Karnataka, Kerala, Rajasthan, Maharashtra, Odisha and Chhattisgarh. Many interior districts in Odisha, Madhya Pradesh, Andhra Pradesh, Punjab, West Bengal and Gujarat have the Telemedicine facility. Presently, ISRO’s Telemedicine Network has enabled 382 Hospitals with the Telemedicine facility. 306 among them are remote/rural/district hospital/health centres and 16 are mobile Telemedicine units, connected to 60 Super Specialty Hospitals located in the major cities. The mobile vans are extensively used for tele-ophthalmology, diabetic screening, mammography, childcare and community health. The Mobile Teleopthalmology facilities provide services to the rural population in ophthalmology care including village level eye camps and vision screening for cataract /glaucoma / diabetic retinopathy. About 150 thousand patients are getting the benefits of Telemedicine every year. Telemedicine in India
  • 32. 30 Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 Ÿ The Centre for Development of Advanced Computing (C-DAC) C-DAC has been working in the area of Health Informatics since early 90s. It has developed several solutions till date in this area. Notably CDAC developed and deployed the first indigenously developed total hospital information system (HIS) software in collaboration with the Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) at Lucknow in 1998. Currently, there are more than 16 hardware and software Telemedicine activities undertaken by C-DAC. 3. Hospitals and Bio-medical Institutions The core part of Telemedicine, be it e-health, mHealth or medical research is the medicine. This is driven by the innovation and standards set by the medical fraternity. Innovation in terms of pioneering mobility in medical instrument, spreading awareness of the benefits, reliability and correct use of tele medical techniques are just a few critical roles taken on by organisations under this stake holder category. In India, hospitals and institutes across varied locations and sizes of operation are continuing to be a part of many initiatives. The most notable contributions have been seen from the Apollo Group and SPGIMS. Other significant participants and premier medical institutions include All-India Institute of Medical Sciences (AIIMS), New Delhi (Jammu & Kashmir, Haryana, Odisha, North East states network), PGIMER12, Chandigarh (Punjab and Himachal state network),Sri Ramachandra Medical College and Research Institute (Andaman & Nicobar Islands), Tata Memorial Hospital and Sir Ganga Ram Hospital, New Delhi, The Amrita Institute of Medical Sciences (AIMS), The Asia Heart Foundation, Fortis Hospital, Narayana Hrudayalaya, and Escorts Heart Institute and Research Centre . Ÿ The Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) SGPGIMS, since its inception, has been actively involved in promoting Telemedicine. It has helped in networking 14 national and international partner nodes and in carrying out tele-education and tele-healthcare activities. It is also actively involved in various research and development activities in collaboration with its technical partners. The institute is also credited with establishing the School of Telemedicine and Biomedical Informatics to train workers in this upcoming field. Ÿ Apollo Hospitals Amongst the latest initiatives, Apollo hospitals is planning to open 1,000 Telemedicine centres in the next three years (2011-14, 1000 days) and is also actively involved in various other eHealth activities, having done over 69,000 tele consultations till date. Apollo Hospitals along with Aircel, has also launched the first Telehealthcare delivery on the mobile for consumers in India. In the past, Ericsson and Apollo had collaborated for a three-month Gramjyoti project, aimed at exploring benefits that can be met for rural India with the advent of internet connectivity and bridging the digital divide. Gramjyoti covered around 18 villages and 15 towns. In September 2010, Apollo Hospitals joined hands with pan-India telecom operator Aircel, to launch the first telehealthcare delivery on the mobile for consumers in India. With a subscriber base of more than 45 million, Aircel is India’s fifth largest service provider, making it an ideal partner for Apollo to launch a mobile healthcare initiative, initially via two dynamic products – Tele Medicine and Tele Triage. Role of Telemedicine Society of India in promoting Telemedicine TSI promotes and encourages development, advancement and research in the science of Telemedicine and its associated fields. It has constantly played a major role in boosting the application of Telemedicine technology in clinical care, education and research in the health sector. TSI fosters networking and collaboration among interest groups in Telemedicine technology and professionals from different streams of science, health care providers, policy makers, NGOs and industry. Telemedicine in India
  • 33. Telehealth Report - 2011 with proceedings of International Telemedicine Congress - 2011 It promotes training of students, health professional, research fellows and technicians, in various aspects of Telemedicine. TSI coordinates with academic institutions and Medical Council of India, AICTE, DOECC and regulating agencies in developing curriculum for Telemedicine training courses and incorporates appropriate modules in the Medical, Dental and Paramedical training programs. TSI has been arranging regular scientific meetings, symposia, seminars and workshops for Telemedicine. It is heading the development of appropriate clinical and industry policies and standards. TSI spreads knowledge in Telemedicine field by publishing brochures, periodicals, journals and has also created an exclusive web site for the society and regularly updates it with Telemedicine news. TSI works in close collaboration with scientific organizations and the industry in development and implementation of innovative products & services related to Telehealth. TSI also organizes trade exhibitions during annual meetings of the society. Public Private Partnership (PPP) An example of a Telemedicine public-private partnership is the collaboration of Narayana Hrudayalaya with the government and ISRO at Chamarajanagar District Hospital (Govt. owned), which is 185 km away from the super specialty cardiac care hospital situated in Bangalore, Karnataka. The network helps provide remote cardiac care to the local population of Chamarajanagar. According to Dr. Devi Prasad Shetty, Chairman, Narayana Hrudayalaya, the unit has treated about 52,000 patients since its inception in 2002. An impact study by an independent evaluating agency on 1,000 patients at the district hospital has reported that the patients who availed Telemedicine consultations spent only 19% of the cost they would have spent if there was a need for them to travel to the nearest city for similar treatment. The Tripura Vision Centre Project is a novel and innovative project in delivering preventive and primary eye care services to remote and underserved areas of Tripura, in North East India. Established in April 2007, the project was designed by IL&FS-ETS, a social infrastructure initiative, in collaboration with Aravind Eye care system, for the State Department of Health. Services are rendered through 40 vision care systems (VC), staffed with trained paramedical ophthalmic assistants. Situated in the premises of Community Information Centre (CICs), the VC can leverage the Tripura State Wide Area Network (TSWAN) and existing infrastructure to connect to the base hospital, IndiraGandhi Memorial (IGM) Hospital, situated in the state capital of Agartala. Here, outpatient department ophthalmologists provide remote consultations through video conferencing and application modules. Preliminary treatment options like prescriptions and spectacles are provided online. Only those requiring special care like surgeries or complicated interventions are required to visit the hospital, thus keeping a check on the logistics and expenditure. Since its inception, the project has now expanded to 35 centres, having screened 71,000 patients till August 2010, among whom approximately 5,000 were referred to the base hospital. It has been estimated that each VC screens around 100 patients per month, thereby having a large impact on the healthcare delivery. The project was recognized by the Government of India and received the National e-Governance Award in 2009. 31 Telemedicine in India