telemedicine narendra malhotra jaideep malhotra neharika malhotra bora rishabh bora www.rainbowhospitals.orgwww.malhotrahospitals.com
What is TelemedicineTelemedicine may be defined as the use of computers and telecommunication technologies to provide medical information and services from distant locations
• Telemedicine comprises all medical actions which extend the action space of health care professional beyond the face-to-face relationship with the patient in the direct surroundings.• It is medicine at a distance. This includes health care delivery, diagnosis, consultation, treatment, educatio n and the transfer of related data.ITU-T Workshop onStandardization in E-Health, 3Geneva, 23-25 May 2003
Objectives of TelemedicineUse of information and communication technologies:i) To provide specialized health care consultation to patients in remote locations,ii) To facilitate video-conferencing among health care experts for better treatment & care,iii) To provide opportunities for continuing education of health care personnel.
Relevance of Telemedicine Inadequate infrastructure in rural/district hospitals Large number of indoor/outdoor patients requiring referral for specialized care Low-availability of Health Experts in district/remote hospitals Dearth of adequate opportunities for training or continuing Medical Education for Doctors in Rural/Remote Health facilities.
Benefits of Telemedicine (I)Benefits to Patients: Access to specialized health care services to under-served rural, semi-urban and remote areas, Access to expertise of Medical Specialists to a larger population without physical referral, Reduced visits to specialty hospitals for long term follow- up care for the aged and terminally ill patients.
Benefits of Telemedicine (II)Benefits to Physicians: Improved diagnosis and better treatment management Access to computerized, comprehensive data (text, voice, images etc.) of patients – offline as well as real time Quick and timely follow-up of patients discharged after palliative care Continuing education or training through video conferencing periodically
Benefits of Telemedicine (III)Hospital and Insurance Benefits: Significant reduction in unnecessary visits & hospitalization for specialized care at tertiary hospitals, Earlier discharge of patients leading to shorter length of stay in hospitals, Increase in the scope of services without creating physical infrastructure in remote hospitals
Implementation challengeITU-T Workshop on Standardization in E-Health, Geneva, 23-25 May 2003 9
Telemedicine : The Model Patient under treatment Physician treating the patient A remote telemedicine console having audio visual and data conferencingNodal Hospital facilities Referral Hospital An expert / specialised doctor A central telemedicine server having audio visual and data conferencing facility
Different types of services Telecardiology Teleradiology Telepathology Telepsychiatry Early Warning System [ Prevention and control of endemic and infectious diseases ]
Benefits of E-Health• Support for diagnostic (primary diagnostic, collaboration, 2nd opinion)• Triage for evacuation of patients• Distant education• Enhancement of collaboration spirit• Diminution of isolation• Use of personal computers for health care.ITU-T Workshop onStandardization in E-Health, Geneva, 23-25 May2003
Telemedicine in India•Existing system limited only to private hospital •CORPORATE Group of Hospitals. •RN Tagore Cardiac Hospital, Calcutta. (Asia Heart Foundation)• No Telemedicine system for public health care•Corporate Sectors Offering Telemedicine Systems •APPOLO & OTHER CORPORATE Groups •Online Telemedicine System, Ahmedabad. •WIPRO GE •SIEMENS
Aim of the Telemedik System• Information management – Patient information – Medical data (signs, symptoms, test reports, etc..) – Appointment scheduling – Archival and retrieval of patient records• Low cost solution – Using ordinary telephone line• Service to large population – Through public health care delivery systems• Development of knowledge-based system – For decision support – For training and education
Why it is relevant to our society Poor infrastructure Non-availability of experts (disparate distribution) Low doctor-patient ratio (large population) Lack of proper medical educationSpecial attention required for Public Health Care System
Medical constraints and challenges• Need and will of cooperation between medical sites;• Complementary function of involved institutions and organizations;• Acceptance of technology and change of working environment;• Interoperability issues ignored. ITU-T Workshop on Standardization in E-Health, Geneva, 23-25 May 2003
Major Challenges•Poor Data Communication Infrastructure.•A Large Population Catered byGovernment Hospitals.•System Features should be scalable.•Cost of the system should be scalable.
Telecommunication constraints• Minimum requirement is reliable telephone line at 19.2KBit/s• Simultaneous Internet access recommended• ISDN permits more advanced solutions like video-conferencing• xDSL for the future. ITU-T Workshop on Standardization in E-Health, Geneva, 23-25 May 2003
Few E-Health Standards applicable• DICOM (Digital Communication Medicine) for medical imaging• ITU H320/H120 for video-conferencing• Proprietary systems for “Store-And-Forward”• Proprietary interactive and collaborative systems ITU-T Workshop on Standardization in E-Health, Geneva, 23-25 May 2003 19
Digital Imaging Communications in Medicine (DICOM ) originally the ACR-NEMA developed by American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) provides standardised formats for image capture and storage coupled with a common information model specifying service definitions and protocols for communication
System Schematic Referral CenterDigital Camera Web Cam PSTN / Leased Line Doctor / Web Cam Scanner Patient Electronics / ISDN / Microscope VSAT Printer Specialist Doctor Scanner Digital camera ECG Machine Printer Electronics Stethoscope Nodal Center
Requirement Specification • A patient getting treatedNodal Hospital • A Doctor • A remote telemedicine console having audio visual and data conferencing facilitiesPOTS / ISDN • An expert/ specialized doctorReferral Hospital • A central telemedicine server having audio visual and data conferencing facility
Sequence of Operation PATIENT IN Patient visits OPD Patient receives local treatment OUT Local Doctor checks up and not referred to telemedicine systemPatient referred to the Telemedicine system (some specialinvestigations may be suggested)Patient visits Telemedicine data-entry console.Operator entries patient record, data and images of test OUTresults, appointment date is fixed for online telemedicinesession Offline Data transfer from Nodal Centre
Sequence of Operation Patient 1 Patient 2 Patient 3 Online conference for the patient. Patient 4 . IN Patient, local doctors at the nodal hospital OUT . and specialist doctors at the referral . hospitalPatient queue
Concept of “Store and Forward” Radiograph PC Scanner Document ScannerITU-T Workshop onStandardization in E-Health, Geneva, 23-25 May 252003
Hardware Configuration Video Conference Modem TelephoneReferral Hospital Microscope and other medical instruments Video Conference PSTN/ISDN/VSAT link Digital camera Scanner Telephone Modem Printer Nodal Hospital
Videoconferencing• Interactive• Well suited for seminars or special case discussion• Less adapted and expensive for routine work• Requires ISDN ITU-T Workshop on Standardization in E-Health, Geneva, 23-25 May 2003
Second opinion telemedicine concept Internet/ISDN/Phone Digitalisation Digitalisation Radiologist Telemedicine Center Pathologist Other Patient Record and Store & Forward Medical Images Medical supervision Telemedicine Private doctor Small clinicITU-T Workshop onStandardization in E-Health, 29Geneva, 23-25 May 2003
The Data• Data related to a patient’s personal information• Data related to a patients medical information• Data for patient management in Telemedicine• Data related to the doctors• Data for system management
Data related to the doctors• Doctor’s personal information• Unique Identification key
Medical information on Internet• Gives valuable on-line access to huge medical knowledge & databases.• Lack of quality control -> www.hon.ch• Language barrier. -> www.etho.org ITU-T Workshop on Standardization in E-Health, Geneva, 23-25 May 2003 38
Schematic Diagram for Proposed Telemedicine using WBSWAN Writers Bldg. State Referral Centre Switching Centre DM OFFICE District Switch Centre Nodal Hospital
…. way forward1. Hand-holding support to Hospital administration for 3-4 years for stabilization of telemedicine services.2. Integration of Telemedicine activities with Health Management Information System for regular reporting (preferably web-based)3. Including Telemedicine activities in the performance appraisal of individuals and institutions.4. Introducing Telemedicine (concept, technical aspects and implementation arrangements) as part of medical education & continuing medical education.