Telemedicine uses telecommunications technology to provide healthcare services from a distance. It can involve real-time video consultations between providers and patients, or storing and forwarding medical images and data for offline review. While telemedicine has benefits like improving access to specialists in rural areas, it still faces barriers like high infrastructure costs, lack of standards and regulations, and reimbursement issues. As technologies improve and costs decrease, telemedicine has great potential to expand healthcare access.

1. Telemedicine Rupak Chakravarty

2. Telemedicine Telemedicine has been defined as the use of telecommunications to provide medical information and services. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at facilities in two countries, using videoconferencing equipment or robotic technology.

3. Telemedicine Telemedicine generally refers to the use of ICT for the delivery of clinical care

5. Telemedicine Types of telemedicine Telemedicine is practiced on the basis of two concepts: real time (synchronous) and store-and-forward (asynchronous)‏

6. Real time telemedicine Real time telemedicine could be as simple as a telephone call or as complex as robotic surgery. It requires the presence of both parties at the same time and a communications link between them that allows a real-time interaction to take place. Video-conferencing equipment is one of the most common forms of technologies used in synchronous telemedicine.

7. Real time telemedicine There are also peripheral devices which can be attached to computers or the video-conferencing equipment which can aid in an interactive examination. For instance, a tele-otoscope allows a remote physician to 'see' inside a patient's ear ; a tele-stethoscope allows the consulting remote physician to hear the patient's heartbeat .

8. Store-and-forward telemedicine Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology, radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of this transfer.

9. Store-and-forward telemedicine Teleradiology, the sending of x-rays, CT scans, or MRIs (store-and-forward images) is the most common application of telemedicine in use today. There are hundreds of medical centers, clinics, and individual physicians who use some form of teleradiology. Many radiologists are installing appropriate computer technology in their homes, so they can have images sent directly to them for diagnosis, instead of making an off-hours trip to a hospital or clinic.

10. Telemedicine Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Specialities that use telemedicine often use a "tele-" prefix; for example, telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as telecardiology, etc.

11. Telemedicine Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location.

12. Telemedicine Telepathology is another common use of this technology. Images of pathology slides may be sent from one location to another for diagnostic consultation. Dermatology is also a natural for store and forward technology (although practitioners are increasingly using interactive technology for dermatological exams). Digital images may be taken of skin conditions, and sent to a dermatologist for diagnosis.

13. Telemedicine The other widely used technology, two-way interactive television (IATV) , is used when a 'face-to-face' consultation is necessary. The patient and sometimes their provider, or more commonly a nurse practitioner or telemedicine coordinator (or any combination of the three), are at the originating site. The specialist is at the referral site, most often at an urban medical center. Video conferencing equipment at both locations allow a 'real-time' consultation to take place. The technology has decreased in price and complexity over the past five years, and many programs now use desktop video conferencing systems.

14. Telemedicine There are many configurations of an interactive consultation, but most typically it is from an urban-to-rural location . It means that the patient does not have to travel to an urban area to see a specialist , and in many cases, provides access to speciality care when none has been available previously. Almost all specialities of medicine have been found to be conducive to this kind of consultation, including psychiatry, internal medicine, rehabilitation, cardiology, paediatrics, obstetrics and gynaecology and neurology.

15. Telemedicine There are also many peripheral devices which can be attached to computers which can aid in an interactive examination. For instance, an tele-otoscope allows a physician to 'see' inside a patient's ear; a tele-stethoscope allows the consulting physician to hear the patient's heartbeat.

16. Teleradiology: Teleradiology is the ability to send radiographic images (x-rays) from one location to another. For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving / image review station. The most typical implementation are two computers connected via Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer so that images can be printed for convenience.

17. Teleradiology: The teleradiology process begins at the image sending station. The radiographic image and a modem or other connection are required for this first step. The image is scanned and then sent via the network connection to the receiving computer.

18. Advantages of Telemedicine: Providing healthcare services via telemedicine offers many advantages. It can make specialty care more accessible to underserved rural and urban populations. Video consultations from a rural clinic to a specialist can alleviate prohibitive travel and associated costs for patients.

19. Advantages of Telemedicine: Video conferencing also opens up new possibilities for continuing education or training for isolated or rural health practitioners, who may not be able to leave a rural practice to take part in professional meetings or educational opportunities. the use of telemedicine can also cut costs of medical care for those in rural areas.

20. Barriers to Telemedicine There are still several barriers to the practice of telemedicine. Many states will not allow out-of-state physicians to practice unless licensed in their state. The Centers for Medicare and Medicaid (CMS) still has several restrictions for Medicare telemedicine reimbursement. Many private insurers also will not reimburse, although some states, such as California and Kentucky, have legislated that they must reimburse the same as for face-to-face consultations.

21. Barriers to Telemedicine Many potential telemedicine projects have been hampered by the lack of appropriate telecommunications technology . Regular telephone lines do not supply adequate bandwidth for most telemedical applications. Many rural areas still do not have cable wiring or other kinds of high bandwidth telecommunications access required for more sophisticated uses.

22. Barriers to Telemedicine Lack of funding for developing state-of-the-art telemedicine infrastructure Some private corporations and telecommunications companies are stepping in to fill the void, however, pressure on the appropriate government and legislative agencies is needed before more funding will become available.

23. Need for Telemedicine in India: The health of a nation is the product of many factors and forces that combine and interact. Economic growth, per capita income, literacy, education, age at marriage, birth rates, information on health care and nutrition, access to safe drinking water, public and private health care infrastructure, access to preventive health and medical care and the health insurance are among the contributing factors . The advances in Medical science, biomedical engineering on one side and Telecommunication and Information Technology on the other side are offering wide opportunities for improved health care.

24. Need for Telemedicine in India: Despite making huge strides in overall development, the health coverage to majority of our population is still a distant dream . India is a vast country gifted with rich and ancient historic background and geographically the nature has provided India with all the varieties like the mountain regions like Ladakh, deserts, green planes and far flung areas in the north east and offshore islands of Andaman’s and Lakshadweep .

25. Need for Telemedicine in India: India today has more than 1 billion population and there is finite limit of elasticity in providing health care in terms of infrastructure, facility, the manpower and the funds. Wide disparities persist between different income groups, between rural and urban communities, and between different states and even districts within States. The population is predominantly rural and distributed in distant geographical locations apart from the high-density urban areas; to provide the basic minimum health care has been one of the priorities of the Health administration all along.

26. Need for Telemedicine in India: Further this is compounded by the following factors like: High cost of health care and lack of investment for health care in rural areas. Inadequate medical facilities in rural & inaccessible areas. Problem of retaining doctors in rural areas where they are required to serve & propagate widespread health awareness. Specialist doctors cannot be retained at rural areas as they will be professionally isolated and become obsolete and even monetary incentives also cannot prevent it.

27. Need for Telemedicine in India: A recent survey by the Indian Medical society has found 75% of qualified consulting doctors practice in urban centers and 23% in semi urban areas and only 2% from rural areas whereas majority of the patients come from rural areas. Hospital beds / 1000 people is 0.19 in rural and 2.2 in urban areas.

28. Need for Telemedicine in India: This calls for innovative methods of utilization of science and technology for the benefit, of our society and telemedicine assumes a great significance to revolutionize the health care system in India. Adaptation of Telemedicine technology offers one of the best options for delivering healthcare for rural & geographically distant population spread across India. Importance of Telemedicine in health care started quite some time ago & more recently the telemedicine has undergone something of resurgence as technology began catching up with the need and aspiration.

29. The Potential Some pilot schemes in telemedicine through the initiative of Department of Space, Department of Information Technology, and some other public & private organizations have demonstrated the successful application of information and Communication technology in extending the reach and access for improved health care to all.

30. Framework in defining the guidelines and standards: Interoperability : Develop telemedicine networks that interface together and create an open environment sharing the application on different participating systems in real-time or seamless interface between several applications Compatibility : Equipment/systems of different vendors and different versions of the same system, to be able to be interconnected

31. Framework in defining the guidelines and standards: Scalability : Equipment/systems inducted for telemedicine to be able to be augmented with additional features and functions as modular add-on options. Portability : The data generated by an application that runs on one system to be able to be ported to different platforms with a minimum effort . Reliability : Telemedicine systems to follow relevant reliability standards of equipment/systems of similar category to ensure availability of service with minimum system downtime.

32. The above framework has been so adopted to ensure: Inclusion of all the stakeholders : Making the recommendation with due consideration of the rights and responsibilities of patient/community, health care service provider, the technology provider, the government etc. Making recommendations vendor neutral : Ensuring that the recommendations are not biased against any specific vendor/manufacturer of telemedicine systems

33. The above framework has been so adopted to ensure: Making standards technology neutral : Ensuring that the recommendations will not favour any specific technology leaving scope for present/future alternatives.

34. Telemedicine Infrastructure: This will include minimum standards for all the hardware and software used in a telemedicine system. Under hardware it will include standards and guidelines for basic telemedicine platform, servers, clinical devices, video conferencing system, communication hardware and power support. The software standards address operating system, telemedicine software, and server software.

35. Telemedicine Infrastructure: Hardware o Telemedicine platform : This will include minimum standards for type of platform to be used, processor/minimum speed, memory requirements, interfaces, and peripherals. o Clinical devices This will include minimum standards for all the clinical devices to be interfaced or integrated with the telemedicine system, including performance specifications for devices measuring diagnostic parameters, imaging devices, compression, and their safety requirements.

36. Telemedicine Infrastructure: Hardware o Video conferencing units o This will include minimum standards for video conferencing system, including data rate, picture resolution, frame rate, type of camera, audio quality etc. o Communication hardware o This will include minimum standards for various hardware used for interfacing the telemedicine system with the communication network, including all types of terrestrial and satellite based networks.

37. Telemedicine Infrastructure: Software o An operating system o Licensed telemedicine S/W with appropriate User Interface(UI) o Back-end Data Base with the mandatory tables/ fields (if applicable)

38. Telemedicine Infrastructure: Connectivity: options for telemedicine services o VSAT o PSTN o ISDN o Leased Line o Wireless LAN /WAN

39. Video conferencing boosts telemedicine Video conferencing is becoming quite popular among hospitals. By using this technology, doctors can help patients who are unable to come to the hospital. It especially benefits the rural populace since one cannot always get good doctors there. Telemedicine has turned out to be a blessing for patients who were otherwise deprived of the best treatment. Polycom is one company that’s providing video conferencing equipment to hospitals for tele-medicine.

40. Video conferencing boosts telemedicine A telemedicine system consists of customised hardware and software at two locations—the patient’s as well as the doctor’s end. These locations are usually connected by means of an Integrated Service Digital Network (ISDN), Public Switch Telephone Network (PSTN) or Very Small Aperture Terminal (VSAT) link, and the system is controlled by the network hub station of the Indian Space Research Organisation (ISRO).

41. Video conferencing boosts telemedicine Polycom India provides video conferencing equipment for tele-medicine. Apollo and Escorts are their principal clients in this area.” The company’s video conferencing solution is called Unified Collaborative Communications (UCC). It helps to provide converged voice, video, web and data solutions for emerging broadband networks, and is designed to integrate with standard video-based medical end-points.

47. http://www.onlinetelemedicine.com/

48. Broadband Broadband has come as a big boost to telemedicine. “With the availability of broadband, India is now becoming a hot destination for tele-medicine as it is a win-win situation for both the patients as well as hospitals.

49. The goal Telemedicine tools help deliver healthcare in medical disciplines like emergency medicine, behavioural science, dermatology, cardiology, radiology, paediatrics, obstetrics, oncology, dentistry, gastro-enterology, neurology, pathology, psychiatry, orthopaedics, family practice, ophthalmology and rheumatology. As Lavanian puts it, “The primary objective of tele-medicine is to provide quality healthcare assistance to every patient.

50. The goal Video conferencing also ensures that the patients are treated irrespective of their financial condition, and this makes it popular in most countries. It is expected that home-based patient monitoring is also going to become popular, as will remote surgery, which will involve surgery via robotics, with the surgeon in one location and the patient in another.

51. Possibilities of Telemedicine Transmission of digitized audio, video, and still images Improvements in quality of care in rural and underserved communities Overcoming isolation of rural practitioners by linking them to urban medical centers Delivery of information and services into the home Monitoring patients at home

52. Possibilities of Telemedicine Keeping patients in the community and maintaining continuity of care Reduction of travel time and expense for physicians and patients Increased mobility as people move from urban to rural areas with continued access to specialists New business and marketing opportunities

53. Barriers to Implementation Ambiguity of multiple definitions and visions Belief among some that implementing telemedicine is the goal rather than the means to a goal High cost of infrastructure and hardware Poorly designed systems Incompatibility of systems Limited bandwidth Outmoded regulations

54. Barriers to Implementation Lack of standards Confidentiality concerns Complex liability issues (for example, where would a law suit be filed?) State-based licensor laws that pose obstacles to practising telemedicine across state lines Lack of guidelines for credential physicians Potential strain on physician-patient relationship Questions about image fidelity and context

55. Barriers to Implementation Distrust and fear of new technologies Disruption of normal office routine Time required to train providers and support personnel Resistance to responsibility for increased number of patients Increased time required for patient referral Increased practice and capitalization costs Difficulty in evaluating cost and quality of care Difficulty in determining value, and added value, of telemedicine

56. Barriers to Implementation Compartmentalization of costs, which reduces incentive to optimize whole system Federal, state, local, and private-sector budget constraints Concerns about overuse--and inappropriate use--of telemedicine Inconsistent reimbursement practices (for example, Medicare reimburses image transmission but not consultation) Political agendas that can derail progress in health-system and telecommunication-system reform Uncertainty on all sides about which elements of telemedicine will work