1. VISION PAPER ON TELEMEDICINE
FOR ARMED FORCES MEDICAL
SERVICES
DR SS GUPTA

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CONTENTS
Introduction.............................................................................................................................. 3
Scope.........................................................................................................................................3
Definition...................................................................................................................................3
Telemedicine personnelpective for ARMED FORCES MEDICAL SERVICES ................... 3
Vision Statement...................................................................................................................... 4
ICT in context to Medicine......................................................................................................4
Stakeholders............................................................................................................................. 4
Building Blocks........................................................................................................................ 5
Implementation......................................................................................................................... 7
Tiers...........................................................................................................................................8
Telemedicine Focus................................................................................................................. 8
Resources............................................................................................................................... 10
Road ahead............................................................................................................................. 10
Steering Gp............................................................................................................................. 10
Conclusion.............................................................................................................................. 10

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VISION TELEMEDICINE FOR ARMED FORCES MEDICAL SERVICES
Introduction
1. Telemedicine, in the broader sense Telehealth, is one of the KRA for
development in armed forces medical services. This is one field where ICT can act
as a force multiplier to reach out to remotest location, as well as, use ICT to improve
medical care.
Scope
2. This paper aims to form the basic document for future work on telemedicine in
the Armed Forces. A large body of work on telemedicine is available on the Internet
covering all aspects of its technology, usage, advantages and limitations. This paper
does not attempt to duplicate the same, the emphasis in this paper are on
telemedicine in context of Armed Forces.
3. Telemedicine, in context of Armed forces, is still in the planning stage, the
environment is yet to understand the advantages and limitation and utilise
telemedicine/ICT gainfully. The awareness can only be increased with focused use
of telemedicine in areas where it is obviously beneficial. This is discussed in more
detail subsequently in this paper.
4. The field of telemedicine is evolving with the new technologies becoming
available and therefore the vision will also evolve with passage of time.
Definition
5. The WHO defines telemedicine as :-
“The delivery of health care services, where distance is a critical factor, by all health
care professionals using information and communication technologies for the
exchange of valid information for diagnosis, treatment and prevention of disease and
injuries, research and evaluation, and for the continuing education of health care
providers, all in the interests of advancing the health of individuals and their
communities”
Telemedicine personnelpective for ARMED FORCES MEDICAL SERVICES
6. The attempt to have a vision of telemedicine for armed forces would require
putting telemedicine in the correct perspective in the current medical environment. It
has to be understood that in the foreseeable future it can neither compete with nor
replace standard medical practice, that of the patient being seen directly by the
doctor.
7. The emphasis for use of telemedicine in the Armed Forces is to complement
the present medical support and extend the expertise to areas bereft of medical
support and to extend medical expertise to areas having less medical expertise,
where it is essential and practical.
8. It allows for enhancement of training, instant access to knowledge base and
on-call information. Telemedicine will work best in areas where patient, doctors and
the organisation benefit from its use especially in areas where all are beneficiaries.

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Vision Statement
9. The vision is to extend, enhance and strengthen the health care delivery
by Armed Forces Medical Services to the armed forces.
10. To elaborate, it is to leverage the capabilities of telemedicine to : -
(a) Extend medical support to areas where none exists such as post or
ships.
(b) Enhance the medical support where the foot print is light ie delivering
expert care to areas without requisite expertise, where practical.
(c) Strengthen the capabilities of armed forces medical services through
online CME, knowledge base and training.
ICT in context to Medicine
11. The ICT has entered the medical field more insidiously as compared to other
sectors. There is no “BC” or before computers point for the medical world however
the last two decades have been watershed years where use of IT has become the
mainstay for evidence based medical practice. Medical care without autoanalysers,
CT scan, USG and an ever increasing list of medical devices both for investigation
and treatment based on the ‘computer on chip’ and hardwired codes is now
unimaginable.
12. The acceptance of IT, therefore, in these areas, is incontrovertible. The
information acquired by devices can be accurately and instantly transmitted to
remote sites for interpretation along with patient information including video
conferencing. However, the computers cannot compete in acquisition of clinical
information given the nuances of human interaction and clinical examination.
13. The symptoms can be vague and histories inaccurate, the art of connecting
disparate information/facts and producing a diagnosis is beyond any computer’s
capability at present. This will remain a future prospect even though it has been
demonstrated that implantable devices can directly feed sensation to humans from
remote robotic hand.
14. In the present context the relaying of information such as ECG from a post
without medical personnel would help in decision making such as urgency of
immediate evacuation weighed against risk to personnel on evacuating in high risk
areas or an opinion of a Radiologist for an X-Ray from peripheral hosp not posted
with a radiologist.
Stakeholders
15. Telemedicine has three primary stakeholders : -
(a) The Healthcare provider. This could be a super specialist reviewing
a chronic case online to medical personnel guiding a non medical
personnel/BFNA in an emergency, where evacuation is not possible.
(b) The patient. The obvious benefits of telemedicine in providing a
means to bring to bear higher skills for benefit the patient; once again it is
reiterated only in situations where its telemedicine is the only means available.

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Also in cases where tele-consultation can be done as a follow up, where
diagnosis is already established.
(c) Armed Forces Medical Services. The organisation will stand to
benefit ultimately due to :-
(i) Optimisation of resources.
(ii) Preventing avoidable transfer of patients.
(iii) Transfer of records ie when the EHR are available.
(iv) Providing an online knowledge base.
(v) Enhance training and education.
Building Blocks
16. The four basic building blocks have to be in place for telemedicine to function.
These are elaborated in subsequent paragraphs :-
(a) Sender.
(b) Responder.
(c) Policies and protocols.
(d) Media.
17. Sender. This includes data acquisition, content, information and the devices
required. These are as under :-
(a) Medical Devices. These could be any medical device generating data
which can be relayed directly or saved and forwarded.
(b) Software. Most of the application in ICT have become web based
therefore the software has become a part of media; however some software
may be required for special task at user end as also for seeing the data sent
back by responder.
(c) Data and information. The information/data can be as voice,
documents, images or streaming media ie video conferencing.
18. Responder. Telemedicine cannot work unless the information is acted upon
and a response given. The issues are as under : -
(a) Centralised Responder. This would necessitate setting up a facility
manned specifically to respond to telemedicine requirements. Other specialists
can be connected to give a response.
(b) A centralised facility will require specific infrastructure as well as
manpower. It will be essential where response is required immediately, since it
has to be a 24x7 manned facility. The usefulness of a single centralised
response centre for the entire Armed Forces may not prove to be effective
solution.
(c) Distributed Response. This would logically be a facility for response
in the zone of responsibility of the designated hosp. The issue of availability of
responder when required will affect the effectiveness. This will work best where
there is direct dependence already on ground such as from post to RAP, where
the MO is directly responsibility for tps and also the comn chain is direct.

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(d) The distributed model may be more functional for the armed forces as
zonal or designated hospital can provide service in its catchment area and it
follows the normal lines of tech control.
(e) The distributed system can be visualised as hub and spoke. The hubs
are linked through a central software to the spokes, so that the each responder
is mapped to specific hops/units and responds to limited number of queries.
Even though it is possible to map any hospital connected on the net as hub and
connect any user to that hub from any geog loc it would be more logical to do it
in a zone of responsibility.
19. Policies and Protocols. That the technology for telemedicine is functional
and available is already well established, hence it is a matter of selection and
procurement. Implementation and use is dependent on acceptance of the means
and directions for its use, therefore formalised and policies and protocols are
essential for any meaningful use of telemedicine.
20. Since there are a number of issues involved, including ethical and legal, the
protocols need to evolve with introduction of tech. Initially telemedicine will need to
be introduced in areas where there are minimal legal and ethical issues and then
improved upon.
21. Polices and protocol and identifying areas for use are the single most
important issue in regards to implementation of the telemedicine in the armed
forces, as every technology required has sufficiently matured to provide desired
results.
22. Media. Network, software and hardware form the basis of telemedicine,
therefore, without reliable media, there can be no telemedicine. Since the internet is
not allowed the respective communication branches of the services will have an
important role.
(a) Hardware.
(i) Medical. The medical devices are readily available off the shelf.
The eqpt will need to be procured as per the facility to be given at a
particular location, such as Dermascope, Otoscope and so on.
(ii) IT. Servers and networks are provided by respective
communication branch of the services. Each service has its own data
centre where telemedicine application can be run. Requisite servers will
have to be dedicated for running the applications.
(b) Datacentre. The data centres are crucial to various aspects of
telehealth/telemed, as all training, e-learning and webcasting application will
reside on the servers in the data centre. Since each service has its own
dedicated data centre this will not be an issue.
(c) Software. Other than store and forward method or point to point relay,
software for the telemedicine is required for: -
(i) Content management.
(ii) Videoconferencing.
(iii) Multiuser control, security and access control.
(iv) Storage incl PACS and DICOM viewer.

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(d) Electronic health Record (EHR). EHR is the ultimate data storage for
the patient records; all records for medical purpose have to be archived as a
mandated legal requirement. Designing and implementing EHR is a challenge
even for a hospital. To do it on an organisation wide scale is an even more
difficult challenge but will have to be implemented in due course of time.
(e) It will be impractical to digitise vast amount of historical paper data. The
implications and issues are many, therefore implementation needs to be spread
over a development period, trial period and a future cut-off date for full
implementation, when all other building blocks of HIS, networking, comn are in
place and assured.
(f) The EHR will serve as storage for both telemedicine and HIS. The
record offices will need to become major stakeholders. The EHR can be broken
into four main components : -
(i) Demographic details incl stats i.e. admission, discharge, OPD
registration and so on.
(ii) Investigation records.
(iii) Treatment records i.e. medicines given.
(iv) Clinical records incl med bds.
(g) Demographic details and investigation records are easier to implement
than clinical records. EHR will need to be based on international/national stds
suitable modified for use in the armed forces. Therefore, this needs a sustained
effort in the near future to be developed, as it affects all aspects of medical
records for HIS, health informatics and telemedicine.
23. The media or the communication channel forms the pipe for sending data
from sender to responder and back. The armed forces have number of different
channels and different security protocol and access control. Each channel provides
different speeds for data comn and the speed decreases with number of users. It
also underlines that there can be no single solution, the solutions will have to
address the available channels/bandwidths in an area and the appropriate solution
implemented.
24. The communication/media channels are as under :-
(a) Radio sets.
(b) Landlines.
(c) Fibre optic cables (OFC) for both voice and data.
(d) Satellite Comn, VSAT and Inmarsat.
Implementation
25. Navy and Air Force already have a well est OFC based intranet, with VSAT
comn on ships being std, the comn channels i.e. media is ready for telemedicine.
Army on the other hand, due to terrain, size, operational requirements, and resource
constraints, has different bandwidths i.e. decreasing bandwidths as one moves to
the periphery. The medical resources also decrease in a similar fashion. These facts
drive the division of telemedicine requirement into three tiers based on bandwidth
available.

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Tiers
26. The requirement of telemedicine has been based on the quality of the intranet
networks as this will decide the solution. The telemedicine requirement has been
conceived broadly as three tiers:-
(a) No connectivity; connecting non-medical personnelonnel/paramedical
personnelonnel to medical officers such as from posts, forward area and
remote areas.
(b) Limited connectivity; connecting doctors and specialists, store and
forward method of telemedicine.
(c) Good connectivity; connecting specialists to super speciality centres,
tele consultations, videoconferencing, virtual classrooms, online CMEs and so
on.
Telemedicine Focus
27. Technologically, telemedicine can be used in almost any field of medicine if
comn channels are available. However, due to various reasons this cannot be done.
More so as there is already heavy workload in major zonal and higher level
hospitals. In some places, it may detract from the time available to doctors to attend
patients under their care.
28. Since it is well established that telemedicine can deliver, The project maybe
small and limited to a particular zone but it has to be practical, sustainable and has
to be supported by policy directives for use.
29. In the given situation there are significant areas that are amenable to
telemedicine where the doctor and patient both stand to benefit. The areas, that may
benefit in the immediate context are given below :-
(a) Combat Zone.
(i) Ships. The Navy has already successfully carried out trials of
VSAT based system which will be implemented. The same system can
be used in the Army and AF where VSAT comn are available.
(ii) Forward Post to RAPs (Regimental Aid Post). Radio based
passing of basic parameters including ECG record have been
successfully done using a hand held Portable Physiological Vital
Parameter Monitor (PPVPM) ie BP, Pulse, Resp rate, SpO2 and ECG.
This for the near future will be the only means for telemedicine where
no other form of communication is available at posts, isolated body of
troops, and actions such as LRPs.
(iii) The PPVPM has been taken up for development with DEBEL for
integrating with an onboard PC to be used as a handheld assistive
system for first Aid and emergencies for BFNAs (Battle Field Nursing
Assistants) it can also include an electronic field medical card.
(iv) RAPS/ADS to Specialist. Equipment such as Biomedical Data
Acquisition System (BIODAS) developed by DEBEL, capable of
acquiring 12 lead ECG, Blood Pressure, Respiration rate, heart rate,
SpO2 and body temperature can be used for telemedicine. It can also
have Dermascope, Otoscope and ultrasound probe connected to it.

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(b) Dermatology. This field lends itself to telemedicine due to the
following :-
(i) The modern high megapixel CCD cameras can record more
details than the eye can see.
(ii) The image can be digitally and optically magnified.
(iii) Once diagnosed, a number of skin diseases need prolonged
treatment and reviews.
(iv) There are limited No. of skin centres, hence follow up and
treatment modification can be done using telemedicine with the patient
reporting to remote medical facility and data being sent over video
conferencing or as store and forward or a combination of both, where
there is low bandwidth.
(c) Radiology. X-Rays machines are increasingly becoming digital and
X-ray films can also be digitised. USG, CT and MRI are already fully digital and
their records can be sent directly. The suggested areas are : -
(i) X-Ray from hosp not posted with radiologist to be reported by
Radiologist where expert opinion is required using telemedicine. The
receiving unit can be designated formally to give responsibility and it
need not be geog co-located.
(ii) Routine X Rays from OPDs of overloaded hosp to be reported
on by Radiologist where work load is less.
(iii) Consultation in difficult cases or sharing for training purpose.
(d) Telehealth.
(i) Knowledge base. Content creation and putting on the net is
already being done by Armed Forces Medical Services (AFMS) such as
DG AFMS memorandums. This can be enhanced by video training
material.
(ii) CMEs. The CMEs being held at AFMC and Command
Hospitals can be relayed by webcasting over the intranet. It is possible
to make it interactive at a later stage.
(iii) E-learning. E-learning and online classrooms can be hosted on
data centre servers. Online courses can be done by doctors as well as
paramedical staff. An experimental site is already functional on DG
AFMS web site on Army intranet.
(iv) EHR. Electronic health records of patients will make
telemedicine more effective as the requisite records will be available
online.

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Resources
30. The crucial aspect of it implementation is dedicating human resources to reply
to a query, a resource which is at a premium. The requirements of telemedicine
cannot override the primary task of caring for patients for whom the doctor is directly
responsible. Therefore the following need to be considered amongst others for
deployment of human resources : -
(a) Patient profiling. To be used for only selected patients who meet the
laid down criteria for a tele-consultation to be allowed.
(b) Scheduling. The scheduling to be done for both patient and doctor to
be online at a specific time.
(c) Store and fwd method to be used so that info is available at local
server prior to consultation.
(d) Designation of hosp as a hub to be done on basis of work load, it may
be considered speciality wise.
Road ahead
31. Telemedicine so far has been done as experiments/demo in the armed forces.
The way ahead is to build it up in places where it is practical and will produce
immediate and tangible results and then evolve as capability, confidence and
technology improves.
Conclusion
32. Even though telemedicine is not a new subject and the awareness of its
capability are high, its role and use for the armed forces have still to be defined.
Further, with the manpower restriction and given workload it will work only in areas
where it improves efficiency of the doctors and has visible results for the patient, at
least in the initial phase.

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Appx ‘A’
ROAD MAP FOR TELEMEDICINE
2012…………………………………2013…………..………………….2014………………..………..2015……………….………2016………..……
Basic data
txnover
Radioset
Dedicatedserver
for tele med
Developmentof
applications
Pilotprojectfor
dermatology
Pilotprojectfor
radiology/med
cats
EHR as part of
Health
informatics
Buildcapacityfor
storage and
archiving