Introduction
Telemedicine is the use of electronic information to communicate technologies to provide
and support healthcare when distance separates the participants.(1)
“Tele” is a Greek word meaning “distance “and “mederi” is a Latin word meaning “to
heal”. Time magazine called telemedicine “healing by wire”. Although initially considered
“futuristic” and “experimental,” telemedicine is today a reality and has come to stay.
Telemedicine has a variety of applications in patient care, education, research, administration
and public health.(2) Worldwide, people living in rural and remote areas struggle
to access timely, good-quality specialty medical care. Residents of these areas often
have substandard access to specialty healthcare, primarily because specialist physicians
are more likely to be located in areas of concentrated urban population. Telemedicine
has the potential to bridge this distance and facilitate healthcare in these remote
areas.(3
4)
History of Telemedicine
While the explosion of interest in telemedicine over the past four or five years makes
it appear as a relatively new use of telecommunications technology, the truth is that
telemedicine has been in use in some form or the other for over thirty years. The
National Aeronautics and Space Administration (NASA) played an important part in the
early development of telemedicine.(5) NASA's efforts in telemedicine began in the
early 1960s when humans began flying in space. Physiological parameters were transmitted
from both the spacecraft and the space suits during missions.(6)
One of the earliest endeavors in telemedicine, Space Technology Applied to Rural Papago
Advanced Health Care (STARPAHC) delivered medical care to the Papago Indian Reservation
in Arizona. It ran from 1972–1975 and was conceived by the NASA. Its goals were to
provide healthcare to astronauts in space and to provide general medical care to the
Papago Reservation.(1) In 1971, 26 sites in Alaska were chosen by the National Library
of Medicine's Lister Hill National Center for Biomedical Communication to see if reliable
communication would improve village healthcare. It used ATS-1, the first in NASA's
series of Applied Technology Satellites launched in 1966. The primary purpose was
to investigate the use of satellite video consultation to improve the quality of rural
healthcare in Alaska.(7) Since 1977, the Telemedicine Centre at the Memorial University
of Newfoundland has worked toward developing interactive audio networks for educational
programs and the transmission of medical data.(1) The North-West Telemedicine Project
was set up in 1984 in Australia to pilot-test a government satellite communications
network (the Q-Network).(1) The project goals were to provide healthcare to people
in five remote towns south of the Gulf of Carpentaria. In 1989, NASA conducted the
first international telemedicine program, Space Bridge to Armenia/Ufa. Under the auspices
of the US/USSR Joint Working Group on Space Biology, telemedicine consultations were
conducted using one-way video, voice and facsimile technologies between a medical
center in Yerevan, Armenia and four medical centers in the US.(7)
Definitions and Concepts
Telemedicine
The World Health Organization (WHO) defines Telemedicine as, “The delivery of healthcare
services, where distance is a critical factor, by all healthcare 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 healthcare providers, all in the interests of
advancing the health of individuals and their communities.”
Telehealth
Telehealth is the use of electronic information and telecommunications technologies
to support long-distance clinical healthcare, patient and professional health-related
education and training, public health and health administration.(8)
Telemedicine Consultation Centre (TCC)
Telemedicine Consulting Centre is the site where the patient is present. In a Telemedicine
Consulting Centre, equipment for scanning / converting, transformation and communicating
the patient's medical information can be available.(9)
Telemedicine Specialty Centre (TSC)
Telemedicine Specialty Centre is a site, where the specialist is present. He can interact
with the patient present in the remote site and view his reports and monitor his progress.(9)
Telemedicine System
The Telemedicine system consists of an interface between hardware, software and a
communication channel to eventually bridge two geographical locations to exchange
information and enable teleconsultancy between two locations.
The hardware consists of a computer, printer, scanner, videoconferencing equipment
etc. The software enables the acquisition of patient information (images, reports,
films etc.). The communication channel enables the connectivity whereby two locations
can connect to each other.(10)
Utility of Telemedicine [Figure 1](1
9
11–13)
Figure 1
A modern telemedicine system
Easy access to remote areas
Using telemedicine in peripheral health set-ups can significantly reduce the time
and costs of patient transportation
Monitoring home care and ambulatory monitoring
Improves communications between health providers separated by distance
Critical care monitoring where it is not possible to transfer the patient
Continuing medical education and clinical research
A tool for public awareness
A tool for disaster management
Second opinion and complex interpretations
The greatest hope for use of telemedicine technology is that it can bring the expertise
to medical practices once telecommunication has been established.
Telementored procedures-surgery using hand robots
Disease surveillance and program tracking
It provides an opportunity for standardization and equity in provision of healthcare,
both within individual countries and across regions and continents.
The Centre for International Rehabilitation recognizes that telecommunication and
telemedicine are important technologies to improve and provide rehabilitation services
in remote areas. Telemedicine cannot be substitutes for physicians in rural areas
especially in developing countries where resources are scarce and public health problems
are in plenty. So it is unrealistic to think at this stage of substituting unwilling
doctors with this technology. However, it can supplement the current health scenario
in a huge way in most countries.
Types of Technology
Two different kinds of technology make up most of the telemedicine applications in
use today. The first, called store and forward, is used to transfer digital images
from one location to another. A digital image is taken using a digital camera, ‘stored’
and then sent (‘forwarded’) by a computer to another location. This is typically used
for nonemergent situations, when a diagnosis or consultation may be made in the next
24-48 hours and sent back. Teleradiology, telepathology and teledermatology are a
few examples.(14)
The other widely used technology, the 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. Videoconferencing equipment at both locations
allow a ‘real-time’ consultation to take place.(15) Almost all specialties of medicine
have been found to be conducive to this kind of consultation including psychiatry,
internal medicine, rehabilitation, cardiology, pediatrics, obstetrics and gynecology
and neurology.(15)
Infrastructure
The telemedicine centers could be broadly classified into the following classes:
Primary Telemedicine Center (PTC)
Secondary Telemedicine Center (STC)
Tertiary Telemedicine Center (TTC)(9)
PTCs would be based in Primary Health Centers, STCs in Secondary Medical Centers and
TTCs in Tertiary Medical Centers. The Hardware requirements / standards will be referred
in the context of the Telemedicine Consulting and Specialist Centres (TCC) and (TSC).(9)
Telecommunication Technologies
The first among the challenging questions arising when planning a telemedicine network
is ‘What is bandwidth?’ Bandwidth is the capacity that determines how quickly bits
may be sent down the channels in a telecommunication medium. Bandwidth is proportional
to the complexity of the data for a given level of system performance.(16) The following
technologies are currently in use:
Integrated Services Digital Network (ISDN)
ISDN is a dial-up (not dedicated but used on a call-by-call basis) digital connection
to the telecommunication carrier. An ISDN line can carry information at nearly five
times the fastest rate achievable using analog modems over POTS (plain old telephone
service).(16)
T-1
This is the backbone of digital service provided to the end user (typically business)
in USA today which transmits voice and data digitally at 1.554 megabits per second
(Mbps). It can be used to carry analog and digital voice, data and video signals and
can even be configured for ISDN service.(16)
Plain Old Telephone Service (POTS)
POTS transmits data at a rate of up to 56 kilobits per second (kbps) (Bezar 1995)
and is the most widely available telecommunication technology in the world. POTS can
be suitable for audio conferencing, store-and-forward communication, Internet and
low bandwidth videophone conferencing.(16)
Internet
The Internet has a strong impact in delivering certain kinds of care to patients.
In a survey of 1,000 Chief Intelligence Officers (CIOs) conducted by Internet Health
Care Magazine, 65% said their organization had a Web presence and another 24% had
one in development. With the increasing proliferation of e-health sites on the Web
today, many consumers are finding access to online patient scheduling, health education,
review of lab work and even e-mail consultations.(16)
Application of Telemedicine in Public Health
An epidemiological Surveillance:(17)
Telemedicine applications for epidemiological surveillance are gradually reaching
new heights with the development of technology such as geographic information systems
(GISs).
It can give new insight into geographical distribution and gradients in disease prevalence
and incidence and valuable insight into population health assessment.
It also provides valuable information of differential populations at risk based on
risk factor profiles.
It helps in differentiating and delineating the risk factors in the population.
It also helps in interventional planning, assessment of various interventional strategies
and their effectiveness.
It can play a pivotal role in anticipating epidemics.
It is an essential tool in real-time monitoring of diseases, locally and globally.
GIS provides the basic architecture and analytical tools to perform spatial-temporal
modeling of climate, environment and disease transmission helpful in understanding
the spread of vector-borne diseases. Remote sensing techniques have been recently
been used in this regard.
A GIS-based method for acquiring, retrieving, analyzing and managing data differs
from traditional modes of disease surveillance and reporting. It facilitates aggregation
and integration of disparate data from diverse sources so it can guide the formulation
of public health programs and policy decisions.
Interactive health communication and disease prevention(17)
Information technology and telemedicine can be used to inform, influence and motivate
individuals and population organizations on health, health-related issues and adoption
of healthy lifestyles. The various approaches and applications can advance and support
primary, secondary and tertiary health promotion and disease prevention agendas.
It can relay information to individuals as well as to the population as a whole. It
can provide an easy access to those living in remote areas.
It enables informed decision-making. It also simplifies the health decision-making
process / or communication between healthcare providers and individuals regarding
prevention, diagnosis or management of a health condition. As a result, the users
are exposed to a broader choice base.
It can go a long way to promote and maintain healthy behaviors in the community.
It can also help in peer information exchange and emotional support. Examples include
online Internet applications that enable individuals with specific health conditions,
needs or issues to communicate with each other, share information and provide / receive
emotional support.
It promotes self-care and domiciliary care practices. Many living in the remote areas
can be benefited by self-management of health problems which will supplement existing
health care services.
It can be a very important tool for the evaluation and monitoring of healthcare services.
Telemedicine in India
In Utopia, every citizen may have immediate access to the appropriate specialist for
medical consultation. In the real world however, this cannot even be a dream. It is
a fact of life that “All Men are equal, but some are more equal than others.” We in
India are at present, unable to provide even total primary medical care in the rural
areas. Secondary and tertiary medical care is not uniformly available even in suburban
and urban areas. Incentives to entice specialists to practise even in suburban areas
have failed.(18)
In contrast to the bleak scenario in healthcare, computer literacy is developing quickly
in India. Healthcare providers are now looking at Telemedicine as their newly found
Avatar. Theoretically, it is far easier to set up an excellent telecommunication infrastructure
in suburban and rural India than to place hundreds of medical specialists in these
places. We have realized that the future of telecommunications lies in satellite-based
technology and fiber optic cables.(18)
The Beginning
The Apollo group of hospitals was a pioneer in starting a pilot project at a secondary
level hospital in a village called Aragonda 16 km from Chitoor (population 5000, Aragonda
project) in Andhra Pradesh. Starting from simple web cameras and ISDN telephone lines
today, the village hospital has a state-of-the-art videoconferencing system and a
VSAT (Very Small Aperture Terminal) satellite installed by ISRO (Indian Space Research
Organisation). Coupled with this was the Sriharikota Space Center project (130 km
from Chennai) which formed an important launch pad of the Indian Space Research Organisation
in this field.(2)
Current Efforts
In India, telemedicine programs are actively supported by:
Department of Information Technology (DIT)
Indian Space Research Organization
NEC Telemedicine program for North-Eastern states
Apollo Hospitals
Asia Heart Foundation
State governments
Telemedicine technology also supported by some other private organizations(13)
DIT as a facilitator with the long-term objective of effective utilization / incorporation
of Information Technology (IT) in all major sectors, has taken the following leads
in Telemedicine:
Development of Technology
Initiation of pilot schemes-Selected Specialty, e.g., Oncology, Tropical Diseases
and General telemedicine system covering all specialties
Standardization
Framework for building IT Infrastructure in health(13)
The telemedicine software system has also been developed by the Centre for Development
of Advanced Computing, C-DAC which supports Tele-Cardiology, Tele-Radiology and Tele-Pathology
etc. It uses ISDN, VSAT, POTS and is used to connect the three premier Medical Institutes
of the country (viz. All India Institute of Medical Sciences (AIIMS), New Delhi, Sanjay
Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow and Post Graduate
Institute of Medical Education and Research (PGIMER), Chandigarh). Now it is being
connected to include Medical centres in Rohtak, Shimla and Cuttack.(13)
The telemedicine system has been installed in the School of Tropical Medicine (STM),
Kolkata and two District Hospitals. In West Bengal, two hospitals where telemedicine
centres have been established are the First Coronary Care Unit inaugurated in Siliguri
District Hospital, Siliguri, West Bengal on 24 June, 2001 and Bankura Sammilani Hospital,
Bankura, West Bengal inaugurated on 21 July, 2001. Apart from the project at STM,
the Second Telemedicine Project has been implemented by Webel ECS at two Referral
Centres (Nil Ratan Sircar Medical College and Hospital (NRS MC and H), Kolkata and
Burdwan MC and H, Burdwan) and four Nodal Centres (Midnapore (W) District Hospital,
Behrampur District Hospital, Suri District Hospital and Purulia District Hospital).
The Project uses a 512 kbps leased line and West Bengal State Wide Area Network (WBSWAN)
(2 Mbps fiber optic link) as the backbone.(19)
In the past three years, ISRO's telemedicine network has expanded to connect 45 remote
and rural hospitals and 15 superspecialty hospitals. The remote / rural nodes include
the offshore islands of Andaman and Nicobar and Lakshadweep, the mountainous and hilly
regions of Jammu and Kashmir including Kargil and Leh, Medical College hospitals in
Orissa and some of the rural / district hospitals in the mainland states.(19)
The Telemedicine project is a “NonProfitable” project sponsored by Rabindranath Tagore
International Institute of Cardiac Sciences (RTIICS) Calcutta, Narayana Hrudayalaya
(NH) Bangalore, Hewlett Packard, Indian Space Research Organisation (ISRO) and the
state governments of the seven North Eastern states of India. The Rabindranath Institute
at Kolkata and Narayana Hrudayalaya at Bangalore will be the main Telemedicine linking
hub for the seven states. The specialists at both the institutions will offer their
services for this project entirely free of charge. A 100 bedded hospital will be identified
in each of these seven states and the hospitals will be selected based on distance
from the state capital and the lack of a coronary care unit.
In the past two years, the pilot project on Telemedicine in Karnataka has already
provided more than 10,000 teleconsultations. In the operational phase, the Karnataka
Telemedicine Project is expected to bring multi-specialty healthcare to a significant
section of the rural population of Karnataka. This network would serve as a model
for the utilization of ‘HEALTHSAT,’ which is proposed for launch in the future.
Challenges(9
15
19)
Perspective of medical practitioners: Doctors are not fully convinced and familiar
with e-medicine.
Patients' fear and unfamiliarity: There is a lack of confidence in patients about
the outcome of e-Medicine.
Financial unavailability: The technology and communication costs being too high, sometimes
make Telemedicine financially unfeasible.
Lack of basic amenities: In India, nearly 40% of population lives below the poverty
level. Basic amenities like transportation, electricity, telecommunication, safe drinking
water, primary health services, etc. are missing. No technological advancement can
change anything when a person has nothing to change.
Literacy rate and diversity in languages: Only 65.38% of India's population is literate
with only 2% being well-versed in English.
Technical constraints: e-medicine supported by various types of software and hardware
still needs to mature. For correct diagnosis and pacing of data, we require advanced
biological sensors and more bandwidth support.
Quality aspect: “Quality is the essence” and every one wants it but this can sometimes
create problems. In case of healthcare, there is no proper governing body to form
guidelines in this respect and motivate the organizations to follow-it is solely left
to organizations on how they take it.
Government Support: The government has limitations and so do private enterprises.
Any technology in its primary stage needs care and support. Only the government has
the resources and the power to help it survive and grow. There is no such initiative
taken by the government to develop it.
Conclusion
It does not require too much of a stretch of imagination to realize that telemedicine
will soon be just another way to see a health professional. Remote monitoring has
the potential to make every minute count by gathering clinical data from many patients
simultaneously. However, information may be lost due to a software glitch or hardware
meltdown. Therefore, relying too heavily on a computer system to prevent errors in
healthcare data may be problematic. There has to be a smart balance between total
dependence on computer solutions and the use of human intelligence. Striking that
balance may make all the difference in saving someone's life. In 2008, the potential
of telemedicine, tele-health and e-health is still left to our imaginations.(20) Time
alone will tell that Telemedicine is a “forward step in a backward direction” or to
paraphrase Neil Armstrong “one small step for IT but one giant leap for Healthcare”.