International Journal for Pharmaceutical Research Scholars

International Journal for Pharmaceutical

Research Scholars (IJPRS) V-3, I-3, 2014 ISSN No: 2277 - 7873 REVIEW ARTICLE

Telemedicine: A Review Bhalani UR*, Shah KV School of Pharmacy, RK University, Kasturbadham, Rajkot, Gujarat, India. Manuscript No: IJPRS/V3/I3/00371, Received On: 22/08/2014, Accepted On: 01/09/2014 ABSTRACT Telemedicine is an upcoming field in health science arising out of the effective fusion of Information and Communication Technologies (ICT) with medical science having enormous potential in meeting the challenges of healthcare delivery to rural and remote areas besides several other applications in education, training and management in health sector. Telemedicine technology can bring revolution in the field of medicine. Using a number of high speed satellite and terrestrial telecommunications link, centralization and coordination of resources and support of government, it is possible to reach and access the population spread out in heterogeneous geographical set up and thus achieve the goal of health for all. Telemedicine can potentially improve health care in developing countries through providing the services in rural and difficult to access parts of the country, providing the possibility of concentration of expertise and resources, reduction of costs for both patients and providers of health services in some aspects. However, the acceptance and further development of telemedicine depends on various factors like cost/benefit analysis, types of telemedicine systems and applications that are mostly required in a special country. KEYWORDS Telemedicine, Telepathology, Tele-cardiology, Teleradiology, Telesurgery, Teleophthalmology, Tele- mentoring, Tele-conferencing INTRODUCTION It may be as simple as two health professionals using two-way video, email, smart phones, discussing medical problems of a patient and wireless tools and other forms of seeking advice over a simple telephone to as telecommunications technology.2 complex as transmission of electronic medical Telemedicine, a term coined in the 1970s, which records of clinical information, diagnostic tests literally means “healing at a distance”3, signifies such as E.C.G., radiological images etc. and the use of ICT to improve patient outcomes by carrying out real time interactive medical video increasing access to care and medical conference with the help of IT based hardware information. and software, video-conference using broadband telecommunication media provided by satellite According to World Health Organization the and terrestrial network.1 Telemedicine includes definition of telemedicine is; “The delivery of a growing variety of applications and services health care services, where distance is a critical factor, by all health care professionals using

*Address for Correspondence: information and communication technologies Bhalani Upasana School of Pharmacy, RK University, for the exchange of valid information for Rajkot-Bhavnagar Highway, diagnosis, treatment and prevention of disease Kasturbadham, Rajkot, Gujarat, India. E-Mail Id: [email protected] and injuries, research and evaluation, and for the continuing education of health care providers,

© Copyright reserved by IJPRS 214 Telemedicine: A Review all in the interests of advancing the health of 1960s in large part driven by the military and individuals and their communities”4 space technology sectors, as well as a few individuals using readily available commercial Starting out over forty years ago with 8,10 demonstrations of hospitals extending care to equipment. patients in remote areas, the use of telemedicine Examples of early technological milestones in has spread rapidly and is now becoming telemedicine include the use of television to integrated into the ongoing operations of facilitate consultations between specialists at a hospitals, specialty departments, home health psychiatric institute and general practitioners at agencies, private physician offices as well as a state mental hospital,11 and the provision of consumer’s homes and workplaces.5 expert medical advice from a major teaching 12 Telemedicine is not a separate medical hospital to an airport medical centre. Recent specialty. Products and services related to advancements in, and increasing availability and telemedicine are often part of a larger utilization of, ICTs by the general population investment by health care institutions in either have been the biggest drivers of telemedicine information technology or the delivery of over the past decade, rapidly creating new clinical care. Patient consultations via video possibilities for health care service and delivery. This has been true for developing countries and conferencing, transmission of still images, e- 13 health including patient portals, remote underserved areas of industrialized nations. monitoring of vital signs, continuing medical The replacement of analogue forms of education, consumer-focused wireless communication with digital methods, combined applications and nursing call centers, among with a rapid drop in the cost of ICTs, have other applications, are all considered part of sparked wide interest in the application of telemedicine and telehealth.5 telemedicine among health-care providers, and have enabled health care organizations to Telemedicine is a significant and rapidly envision and implement new and more efficient growing component of healthcare in the United ways of providing care.8,10 The introduction and States. There are currently about 200 popularization of the internet has further telemedicine networks, with 3,500 service sites accelerated the pace of ICT advancements, in the US. Nearly 1 million Americans are thereby expanding the scope of telemedicine to currently using remote cardiac monitors and in encompass Web-based applications (e.g. e-mail, 2011, the Veterans Health Administration teleconsultations and conferences via the delivered over 300,000 remote consultations internet) and multimedia approaches (e.g. digital using telemedicine. Over half of all U.S. imagery and video). hospitals now use some form of telemedicine. 5,16,17 Around the world, millions of patients use Types of Telemedicine Process telemedicine to monitor their vital signs, remain Telemedicine process can be categorised in two healthy and out of hospitals and emergency ways i.e. technology involved and application rooms. Consumers and physicians download adopted. health and wellness applications for use on their Technology involved cell phones.6,7 6,7,8 Telemedicine can be broken into three main Origins and History categories: store-and-forward, remote Historically, telemedicine can be traced back to monitoring and (real-time) interactive services. the mid to late 19th century (H) with one of the (1) Store-and-forward telemedicine or first published accounts occurring in the early Asynchronous: 20th century when electrocardiograph data were transmitted over telephone wires.9 Store-and-forward telemedicine involves Telemedicine, in its modern form, started in the acquiring medical data (like medical images, biosignals etc.) and then transmitting this data to

Telemedicine: A Review a doctor or medical specialist at a convenient (2) Real Time or Synchronous: time for assessment offline.16 It does not require 17 Real time telemedicine could be as simple as a the presence of both parties at the same time. telephone call or as complex as telemedical Tele-pathology, tele-radiology, tele- video conference and tele-robotic surgery. It dermatology are common specialties that are requires the presence of both parties at the same conducive to asynchronous telemedicine. A time and a telecommunication link between properly structured medical record preferably in them that allows a real-time interaction to take electronic form should be a component of this place. Video-conferencing equipment is one of transfer. A key difference between traditional the most common forms of technology used in in-person patient meetings and telemedicine synchronous telemedicine. encounters is the omission of an actual physical examination and history. The 'store-and- (3) Interactive telemedicine services: forward' process requires the clinician to rely on Interactive telemedicine services provide real- history report and audio/video information in time interactions between patient and provider, lieu of a physical examination. to include phone conversations, online Remote monitoring, also known as self- communication and home visits.17 Many monitoring or testing, enables medical activities such as history review, physical professionals to monitor a patient remotely examination, psychiatric evaluations and using various technological devices. This ophthalmology assessments can be conducted method is primarily used for managing chronic comparably to those done in traditional face-to- diseases or specific conditions, such as heart face visits. In addition, "clinician-interactive" disease, diabetes mellitus, or asthma. These telemedicine services may be less costly than in- services can provide comparable health person clinical visit. outcomes to traditional in-person patient Application Adopted17 encounters, supply greater satisfaction to patients, and may be cost-effective.  Telepathology  Tele-cardiology  Teleradiology  Telesurgery  Teleophthalmology Services Provided by Telemedicine18,19  Primary care and specialist referral services may involve a primary care or allied health professional providing a consultation with a patient or a specialist assisting the primary care physician in rendering a diagnosis. This may involve the use of live interactive video or the use of store and forward transmission of diagnostic images, vital signs and/or video clips along with patient data for later review.  Remote patient monitoring, including home telehealth, uses devices to remotely collect and send data to a home health Figure 1: Telemedicine Concept14,15 agency or a remote diagnostic testing facility

Telemedicine: A Review (RDTF) for interpretation. Such applications Delivery Mechanisms 5,21,22,23 might include a specific vital sign, such as  Networked programs link tertiary care blood glucose or heart ECG or a variety of hospitals and clinics with outlying clinics indicators for homebound patients. Such and community health centers in rural or services can be used to supplement the use suburban areas. The links may use dedicated of visiting nurses. high-speed lines or the internet for  Consumer medical and health telecommunication links between sites. information includes the use of the internet  Monitoring center links are used for and wireless devices for consumers to obtain cardiac, pulmonary or fetal monitoring, specialized health information and on-line home care and related services that provide discussion groups to provide peer-to-peer care to patients in the home. Often normal support. land-line or wireless connections are used to  Direct patient care such as sharing audio, communicate directly between the patient video and medical data between a patient and the center, although some systems use and a health professional for use in the internet. rendering a diagnosis, treatment plan,  Web-based e-health patient service sites prescription or advice. This might involve provide direct consumer outreach and patients located at a remote clinic, a services over the Internet. Under physician’s office or home.20 telemedicine, these include those sites that  Medical education provides continuing provide direct patient care. medical education credits for health Types of Connectivity professionals and special medical education seminars for targeted groups in remote  Point-to-Point communication: Point-to- locations.20 point connections using private high speed networks are used by hospitals and clinics Continuing Medical Education (CME) that deliver services directly or outsource Configuration specialty services to independent medical service providers. Such outsourced services include radiology, stroke assessment, mental TV Monitor health and intensive care services. In networking, the Point-to-Point Protocol (PPP), is a data link protocol commonly Antenna LCD Projector Mixer/Switcher & ODU used to establish a direct connection between two nodes over terristrial and satellite link e.g. SGPGIMS, Lucknow is Video Camera DVB-RCS connected to the medical colleges of Orissa In-Door Unit through point to point connectivity via satellite link and district hospital, Rae Bareli 24 Hub/Switch via fiber optic cable network. Microphone  Point-to-multipoint communication: It is a term used in the telecommunication field Document which refers to communication which is Camera Server(s) accomplished via a specific and distinct type Scanner Work Station (s) of multipoint connection, providing multiple paths from a single location to multiple Figure 2: Continuing Medical Education locations e.g. two district hospitals of Configuration 20

Telemedicine: A Review

Uttaranchal state are linked to SGPGIMS  Cost Efficiencies: Reducing or containing via ISDN link.24 the cost of healthcare is one of the most important reasons for funding and adopting Point to point System telehealth technologies. Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better Patient end 12 Lead ECG Doctor end management of chronic diseases, shared A3 Scanner health professional staffing, reduced travel 5, SkyIp times, and fewer or shorter hospital stays. Terminal Video Conferencing 25, 26 Camera SkyIp or OR FlexiDama Digital  Improved Quality: Studies have Switch Terminal Camera Video Conferencing consistently shown that the quality of Camera healthcare services delivered via telemedicine is as good as those given in Hub/Switch traditional in-person consulations. In some TV Monitor Doctor-End specialties, particularly in mental health and TV Monitor Station ICU care, telemedicine delivers a superior District Client Station product, with greater outcomes and patient satisfaction. 5,25,26 Figure 3: Point-to-Point communication20  Patient Demand: Consumers want telemedicine. Telemedicine technologies Point-to-Multipoint System Configuration reduce travel time and related stresses for the patient. Telemedical services offer patients the access to providers that might not be available otherwise, as well as medical services without the need to travel long distances.5,25,26 Telemedicine can be beneficial to patients living Super Specialty Hospital Rural/District Hospital in isolated communities and remote regions, who can receive care from doctors or specialists Server Patient-End far away without the patient having to travel to visit them.27 Recent developments in mobile collaboration technology can allow healthcare professionals in multiple locations to share information and discuss patient issues as if they were in the same place.28 Remote patient Doctor-End Doctor-End Doctor-End monitoring through mobile technology can Figure 4: Point-to-multipoint communication20 reduce the need for outpatient visits and enable remote prescription verification and drug Benefits/Advantages of Telemedicine administration oversight, potentially  Improved Access: Telemedicine has been significantly reducing the overall cost of used to bring healthcare services to patients medical care.29 Telemedicine can also facilitate in distant locations. Not only does medical education by allowing workers to telemedicine improve access to patients but observe experts in their fields and share best it also allows physicians and health facilities practices more easily.30 to expand their reach, beyond their own 5,25,26 The main objective of telemedicine is to cross offices. the geographical barriers and provide healthcare

Telemedicine: A Review facilities to rural and remote areas (health for provider and a patient. Presenters may include all) so it is beneficial for the population living in licensed professionals, parents, spouses, or isolated communities. Besides this other allied health professionals, depending upon advantages of telemedicine are; resources within the community and the expertise required to achieve an adequate  Eliminate distance barriers and improve access to quality health services portrayal of the patient’s mental and physical condition. Requirements for a presenter vary  In emergency and critical care situations widely, based upon the specific patient care where moving a patient may be undesirable settings, the clinical specialty, and expertise of and/or not feasible the telemedicine providers. The most qualified  Facilitate patients and rural practitioners’ telepresenter may in reality, be a lay individual access to specialist health services and in a community trained in the use of support telemedicine technology and who is able to assist the patient. In addition, the evaluating  Lessen the inconvenience and/or cost of provider must be skilled in leveraging the patient transfers telemedicine resources to guide the remote  Reduce unnecessary travel time for health assessment and obtain necessary information for professionals determining diagnoses, treatments, and/or care directives.  Reduce isolation of rural practice by upgrading their knowledge through tele- This expert opinion consensus document education or tele-CME31 focuses on interactive videoconferencing-based telepresenting for health care professionals who Recommendations for Videoconferencing- 32,33,34,6,7 are competent in skills and knowledge required based Telepresenting to assist the remote provider, and serves as a New challenges and opportunities for the guide for health professionals engaging lay provider have been created by the expansion of presenters, such as family members. The communication technologies and new health purpose of this document is to define the care delivery models, as a means to enhance requirements for serving as a telepresenter, as delivery of health care. The use of well as identifying key points to be considered telemedicine/telehealth has extended the reach throughout the process of telepresenting. The of the provider, but also may create situations in document is divided into administrative, which assistance is needed in facilitating clinical technical, and clinical domains. data transfer from the remote patient setting. A Telemedicine has transformed the delivery of telepresenter (presenter) is frequently used, healthcare, yet, successful use of technology is although not always required, to address the dependent upon efficient information exchange. challenges that the consulting provider faces It is the presenter who supports communication when conducting a physical examination using and physical requirements of both the patient telemedicine and to ensure efficient information and evaluating provider throughout the tele- exchange. The presenter is an individual, encounter process. located at the patient remote site that provides support to the patient and the telemedicine Applications of Telemedicine35 consulting provider, in completing the physical 1. Tele-health care: It is the use of examination and/or telemedicine activity. information and communication technology The role of presenter will continue to evolve as for prevention, promotion and to provide telemedicine and technology advance, however, health care facilities across distance. It can presenters are frequently employed to assist be divided in the following activities with real-time, interactive videoconferencing - Teleconsultation based consultations between a health care

Telemedicine: A Review - Telefollow-up human interaction between medical professionals and patients, an increased risk of 2. Tele-education: Tele-education should be error when medical services are delivered in the understood as the development of the absence of a registered professional, and an process of distance education (regulated or increased risk that protected health information unregulated), based on the use of may be compromised through electronic storage information and telecommunication and transmission.36 technologies, that make interactive, flexible and accessible learning possible for any There is also a concern that telemedicine may potential recipient. actually decrease time efficiency due to the difficulties of assesing and treating patients 3. Disaster Management: Telemedicine can through virtual interactions; for example, it has play an important role to provide healthcare been estimated that a teledermatology facilities to the victims of natural disasters consultation can take up to thirty minutes, such as earthquake, tsunami, tornado, etc. whereas fifteen minutes is typical for a and man-made disaster such as war, riots, traditional consultation.37 Additionally, etc. During disaster, most of the terrestrial potentially poor quality of transmitted records, communication links either do not work such as images or patient progress reports, and properly or get damaged so a mobile and decreased access to relevant clinical information portable telemedicine system with satellite are quality assurance risks that can compromise connectivity and customized telemedicine the quality and continuity of patient care for the software is ideal for disaster relief. reporting doctor.36 Other obstacles to the 4. Tele-home health care: Telemedicine implementation of telemedicine include unclear technology can be applied to provide home legal regulation for some telemedical practices health care for elderly or underserved, and difficulty claiming reimbursement from homebound patients with chronic illness. It insurers or government programs in some allows home healthcare professionals to fields.38 monitor patients from a central station rather Barriers in Telemedicine Practice39 than travelling to remote areas chronically ill or recuperating patients for routine check- Physician/Patient Acceptance ups. Remote patient monitoring is less Physicians and patients have unique expensive, more time savings, and efficient technological resources available to improve the methodology. Tele-home care virtual visits patient-physician relationship. It has been found might lead to improved home health care that patients have no difficulty in accepting quality at reduced costs, greater patient telemedicine program. The survey conducted by satisfaction with care, increased access to SGPGIMS tele-follow up program for the health care providers and fewer patients patients of Orissa state revealed that 99% needing transfer to higher, more costly patients were satisfied with using telemedicine levels of care. A Computer Telephone technology. In almost all the cases the patients Integrated (CTI) system can monitor vital are more than happy and satisfied as they don’t functions of patients twenty four hours a day have to travel 1500 km to show their diagnostic and give immediate warnings. reports to their doctors. In tele-consultation they Draw backs were also happy that they get the specialist consultation and their cases has been seen by The downsides of telemedicine include the cost some expert doctors. of telecommunication and data management equipment and of technical training for medical However, some resistance is seen amongst personnel who will employ it. Virtual medical doctors. Doctors in government sector tend to treatment also entails potentially decreased look upon telemedicine as an additional duty or

Telemedicine: A Review workload. Therefore, there is need to weave have to decide whether the cost of tele- telemedicine into the routine duties of the healthcare should be reimburse or not. doctors. The private doctors sometime fear that Lack of Trained Manpower telemedicine is likely to reduce their practice. They need to realize that this technology Telemedicine is a new emerging field, there is enhances their reach and exposure and is only lack of training facilities with regards to likely to increase their practice further. application of IT in the field of medicine. Most of the healthcare and IT professionals are not Availability of Technology at a Reasonable familiar with the terms commonly used in Cost telemedicine such as HIS, EMR, PACS, etc. It is myth that to establish a telemedicine Telemedicine is also not the part of course platform is an expensive. The basic system curriculum of medical schools. needs hardware, software and Legal & Ethical telecommunication link. In all the areas there is a significant reduction in the prices. Most of Telemedicine technology has been proved and these costs are well within the reach of most of established and its advantages and benefits are the hospitals, and can be recovered by nominal well known but still many healthcare charge to the patients and students in case of professionals are reluctant to engage in such tele-education which would be much less than practices due to unresolved legal and ethical the physically traveling. concerns. In case of a cross-border teleconsultation which country’s litigation laws will Accessibility be applied in case – those of the country in Although information technology has reached in which the patient is living or those of the remote all corner of the country but the accessibility of physician? people living in remote and rural area to the Privacy and Security Concerns nearest health center (PHCs, CHCs or district hospital) may not be easy due to poor There are many issue that should be considered infrastructure of road and transport. It may be regarding the security, privacy and possible that the available telemedicine system confidentiality of patient data, in telemedicine in the health centers may not function because consultations i.e, how are patients’ rights of of the interruption in power supply. confidentiality of their personal data ensured and protected?, how to ensure security of the Reliability data and restrict its availability to only those for Some healthcare professionals has doubt about whom it is intended and who are authorised and the quality of images transmitted for tele- entitled to view it?, how to prevent misuse and consultation and tele-diagnois. In tele-radiology, even abuse of electronic records in the form of telepathology, tele-dermatology the quality of unauthorised interception and/or disclosure? image (colour, resolution, field of view, etc) Expected Problems with Telemedicine in should be international standards to avoid any Third World Countries40 wrong interpretation and mis-diagnosis. The delay in transmission of data may be of critical Financial importance in tele-mentoring and robotic • Increase of costs because of improving the surgery and have to be reduced to the minimum. quality of service through providing second Funding/ Reimbursement Issues opinion There should be a format to calculate the • Who pays for the expenses investment and recurring cost of the • Cost effectiveness assessment telemedicine system. The insurance companies

Telemedicine: A Review

Liability  Demonstration and teaching techniques or • Who is responsible for the patient? procedures on patients as an adjunct teacher when a qualified preceptor is on-site with • Anyone can establish a web site to offer the student. consulting Tele-Conferencing43 Acceptance Tele-conferencing is the discussion and • Physicians resist to use a new technology interaction between doctors during workshop, that they do not understand conferences, seminar or continual medical • Patients and doctors are accustomed to education programs in a visual room personal visits and are reluctant to alter the environment. Live surgery demonstration or traditional method of care procedures can be transmitted through videoconference during these programs. One of • Privacy and confidentiality of information the widely used technology it has now changed • Insurance the concept of physical presence in any of the above events. Technology Different kinds of teleconferencing modalities • Scarcity of high-bandwidth are now in use such as interactive two way, one telecommunication networks in rural areas way broadcast, web cast etc. Once the cost of • Compatibility of old equipment with broadband telecommunication comes down and telemedicine internet technology is advanced more and more people would like to stay afoot at their place of Main Pillars of Telemedicine41,42,43 work and participate in events remotely. Tele-Mentoring /Tele-Proctoring42,43 Tele-Consultation43 It is mentoring and evaluation of surgical Evaluation of patient(s), and/or patient data, and trainees from distance with the involvement of consultation regarding patient management, broadband connectivity, power cams, and from a distant site, using a telecommunications sophisticated videoconferencing equipment. A interface. The teleconsultant, by definition, does real time and live interactive teaching of not have the ability to physically interact with techniques or procedures by a teleproctor to a the patient, except through the student. The teleproctor is in one location and telecommunications interface. the student is in another. Appropriate Use: The teleproctor must have the ability to see the performance of the procedure or technique  Initial urgent evaluation of patients, triage being executed by the student in real time. The decisions, and pretransfer arrangements for teleproctor and the student must have the ability patients in an urgent/emergency situation to verbally communicate during the session.  Intra-operative consultations Implicit in the definition of teleproctoring is that the teleproctor does not have the ability to  Supervision and consultation for primary physically intervene on-site and can therefore care encounters in sites where an not assume primary patient care responsibility. equivalently qualified physician/surgeon is not available Appropriate use:  Routine consultations and second opinions  Demonstration and/or teaching technique or based on history, physical findings, and procedures using inanimate trainers. available test data  Demonstration and/or teaching techniques or  Public health, preventive medicine, and procedures using animate ex vivo models. patient education

Telemedicine: A Review

Different Types of Telemedicine Systems  Regulatory challenges related to the according to their use in Health care44 difficulty and cost of obtaining licensure • Tele-education across multiple states, malpractice protection and privileges at multiple • Medical emergencies and distant facilities • Teleconsultation  Lack of acceptance and reimbursement by • Telediagnosis relief government payers and some commercial insurance carriers creating a major financial • Telesurgery and virtual reality barrier, which places the investment burden Different Types of Telemedicine Systems squarely upon the hospital or healthcare according to the Medical Applications44 system. • Teleradiology  Cultural barriers occurring from the lack of desire, or unwillingness, of some physicians • X- Ray to adapt clinical paradigms for telemedicine • CT applications.46 • MRI General Health Care Delivery47 • NM (Nuclear Medicine) The first interactive telemedicine system, operating over standard telephone lines, • Fluoroscopy designed to remotely diagnose and treat patients • Angiography requiring cardiac resuscitation (defibrillation) • Ultrasound was developed and launched by an American company, MedPhone Corporation, in 1989. A • Thermography year later under the leadership of its • Telepathology President/CEO S Eric Wachtel, MedPhone introduced a mobile cellular version, the • Teledermatology MDPhone. Twelve hospitals in the U.S. served • Tele-endoscopy as receiving and treatment centers.48 • Telecardiology In general, a patient will have a number of monitoring devices at home, and the results of • Telepsychiatry these devices will be transmitted via telephone • Telepharmacy to the health care provider. Telemonitoring is a • Telemetry convenient way for patients to avoid travel and to perform some of the more basic work of Emergency Telemedicine45 healthcare for themselves. U.S. Navy medical staff being trained in the use In addition to objective technological of handheld telemedical devices (2006). monitoring, most telemonitoring programs Common daily emergency telemedicine is include subjective questioning regarding the performed by SAMU Regulator Physicians in patient's health and comfort. This questioning France, Spain, Chile, Brazil. Aircraft and can take place automatically over the phone, or maritime emergencies are also handled by telemonitoring software can help keep the SAMU centres in Paris, Lisbon and Toulouse.45 patient in touch with the health care provider. The provider can then make decisions about the A recent study identified three major barriers to patient's treatment based on a combination of adoption of telemedicine in emergency and subjective and objective information similar to critical care units. They include: what would be revealed during an on-site appointment.

Telemedicine: A Review Some of the more common things that telehealth, and has many points of contacts with telemonitoring devices keep track of include other medical and non-medical applications, blood pressure, heart rate, weight, blood such as telediagnosis, teleconsultation, glucose, and hemoglobin. Telemonitoring is telemonitoring, etc. capable of providing information about any vital Telenursing is achieving significant growth signs, as long as the patient has the necessary rates in many countries due to several factors: monitoring equipment at his or her location. the preoccupation in reducing the costs of health Depending on the severity of the patient's care, an increase in the number of aging and condition, the provider may check these chronically ill population, and the increase in statistics on a daily or weekly basis to determine coverage of health care to distant, rural, small or the best course of treatment. sparsely populated regions. Among its benefits, The first Ayurvedic telemedicine center was telenursing may help solve increasing shortages established in India in 2007 by Partap Chauhan, of nurses; to reduce distances and save travel an Indian Ayurvedic doctor and the Director of time, and to keep patients out of hospital. A Jiva Ayurveda. Teledoc used Nokia phones greater degree of job satisfaction has been running Javascript to link mobile ayurvedic field registered among telenurses. techs with doctors in the Jiva Institute clinic; at Telepharmacy50 its peak, Teledoc reached about 1,000 villagers per month in Haryana province, primarily Telepharmacy is the delivery of pharmaceutical treating chronic diseases such as diabetes. care via telecommunications to patients in locations where they may not have direct Monitoring a patient at home using known contact with a pharmacist. It is an instance of devices like blood pressure monitors and the wider phenomenon of telemedicine, as transferring the information to a caregiver is a implemented in the field of pharmacy. fast growing emerging service. These remote Telepharmacy services include drug therapy monitoring solutions have a focus on current monitoring, patient counselling, prior high morbidity chronic diseases and are mainly authorization and refill authorization for deployed for the First World. In developing prescription drugs, and monitoring of formulary countries a new way of practicing telemedicine compliance with the aid of teleconferencing or is emerging better known as Primary Remote videoconferencing. Remote dispensing of Diagnostic Visits, whereby a doctor uses medications by automated packaging and devices to remotely examine and treat a patient. labeling systems can also be thought of as an This new technology and principle of practicing instance of telepharmacy. Telepharmacy medicine holds significant promise of services can be delivered at retail pharmacy improving on major health care delivery sites or through hospitals, nursing homes, or problems, in for instance, Southern Africa, other medical care facilities. because Primary Remote Diagnostic Consultations not only monitors an already The term can also refer to the use of diagnosed chronic disease, but has the promise videoconferencing in pharmacy for other to diagnose and manage the diseases patients purposes, such as providing education, training, will typically visit a general practitioner for. and management services to pharmacists and pharmacy staff remotely.38 Telenursing49 Telerehabilitation51,52 Telenursing refers to the use of telecommunications and information technology Telerehabilitation or e-rehabilitation is the in order to provide nursing services in health delivery of rehabilitation services over care whenever a large physical distance exists telecommunication networks and the between patient and nurse, or between any Internet.51,52 Most types of services fall into two number of nurses. As a field it is part of categories: clinical assessment (the patient’s

Telemedicine: A Review functional abilities in his or her environment), "Rehabilitation Engineering and Research and clinical therapy. Some fields of Center" (RERC) at the University of Pittsburgh, rehabilitation practice that have explored the Rehabilitation Institute of Chicago, the State telerehabilitation are: neuropsychology, speech- University of New York at Buffalo, and the language pathology, audiology, occupational National Rehabilitation Hospital in Washington therapy and physical therapy. Telerehabilitation DC. Other federal funders of research are the can deliver therapy to people who cannot travel Veterans Administration, the Health Services to a clinic because the patient has a disability or Research Administration in the US Department because of travel time. Telerehabilitation also of Health and Human Services, and the allows experts in rehabilitation to engage in a Department of Defense. Outside the United clinical consultation at a distance. States, excellent research is conducted in Most telerehabilitation is highly visual. As of Australia and Europe. 2006 the most commonly used modalities are As of 2006, only a few health insurers in the via webcams, videoconferencing, phone lines, United States will reimburse for videophones and webpages containing rich telerehabilitation services. If the research shows internet applications. The visual nature of that teleassessments and teletherapy are telerehabilitation technology limits the types of equivalent to clinical encounters, it is more rehabilitation services that can be provided. It is likely that insurers and Medicare will cover most widely used for neuropsychological telerehabilitation services. rehabilitation; fitting of rehabilitation equipment Teletrauma Care53,54,55,56 such as wheelchairs, braces or artificial limbs; and in speech-language pathology. Rich internet Telemedicine can be utilized to improve the applications for neuropsychological efficiency and effectiveness of the delivery of rehabilitation (aka cognitive rehabilitation) of care in a trauma environment. Examples cognitive impairment (from many etiologies) include: was first introduced in 2001. This endeavor has Telemedicine for trauma triage: expanded as a teletherapy application for cognitive skills enhancement programs for Using telemedicine, trauma specialists can school children. Tele-audiology (hearing interact with personnel on the scene of a mass assessments) is a growing application. As of casualty or disaster situation, via the internet 2006, telerehabilitation in the practice of using mobile devices, to determine the severity occupational therapy and physical therapy are of injuries. They can provide clinical very limited, perhaps because these two assessments and determine whether those disciplines are more "hands on". injured must be evacuated for necessary care. Remote trauma specialists can provide the same Two important areas of telerehabilitation quality of clinical assessment and plan of care as research are; (1) demonstrating equivalence of a trauma specialist located physically with the assessment and therapy to in-person assessment patient. 53 and therapy, and (2) building new data collection systems to digitize information that a Telemedicine for intensive care unit (ICU) therapist can use in practice. Ground-breaking rounds: research in telehaptics (the sense of touch) and Telemedicine is also being used in some trauma virtual reality may broaden the scope of ICUs to reduce the spread of infections. Rounds telerehabilitation practice, in the future. are usually conducted at hospitals across the In the United States, the National Institute on country by a team of approximately ten or more Disability and Rehabilitation Research (NIDRR) people to include attending physicians, fellows, supports research and the development of residents and other clinicians. This group telerehabilitation. NIDRR's grantees include the usually moves from bed to bed in a unit discussing each patient. This aids in the

Telemedicine: A Review transition of care for patients from the night Willem Einthoven, the inventor of the ECG, shift to the morning shift, but also serves as an actually did tests with transmission of ECG via educational experience for new residents to the telephone lines. This was because the hospital team. A new approach features the team did not allow him to move patients outside the conducting rounds from a conference room hospital to his laboratory for testing of his new using a video-conferencing system. The trauma device. In 1906 Einthoven came up with a way attending, residents, fellows, nurses, nurse to transmit the data from the hospital directly to practitioners, and pharmacists are able to watch his lab.47 a live video stream from the patient’s bedside. Teletransmission of ECG using Methods They can see the vital signs on the monitor, Indigenous to Asia59 view the settings on the respiratory ventilator, and/or view the patient’s wounds. Video- One of the oldest known telecardiology systems conferencing allows the remote viewers two- for teletransmissions of ECGs was established way communication with clinicians at the in Gwalior, India in 1975 at GR Medical bedside.54 College by Dr. Ajai Shanker, Dr. S. Makhija, P.K. Mantri using an indegenous technique for Telemedicine for trauma education: the first time in India. Some trauma centers are delivering trauma This system enabled wireless transmission of education lectures to hospitals and health care ECG from the moving ICU van or the patients providers worldwide using video conferencing home to the central station in ICU of the technology. Each lecture provides fundamental department of Medicine. Transmission using principles, firsthand knowledge and evidenced- wireless was done using frequency modulation based methods for critical analysis of which eliminated noise. Transmission was also established clinical practice standards, and done through telephone lines. The ECG output comparisons to newer advanced alternatives. was connected to the telephone input using a The various sites collaborate and share their modulator which converted ECG into high perspective based on location, available staff, 55 frequency sound. At the other end a and available resources. demodulator reconverted the sound into ECG Telemedicine in the trauma operating room: with good gain accuracy. The ECG was Trauma surgeons are able to observe and converted to sound waves with a frequency consult on cases from a remote location using varying from 500 Hz to 2500 Hz with 1500 Hz video conferencing. The remote surgeon has the at baseline. capability to control the camera (pan, tilt and This system was also used to monitor patients zoom) to get the best angle of the procedure with pacemakers in remote areas. The central while at the same time providing expertise in control unit at the ICU was able to correctly order to provide the best possible care to the interpret arrhythmia. This technique helped patient.56 medical aid reach in remote areas.59 Specialist care delivery: In addition, electronic stethoscopes can be used Telemedicine can facilitate specialty care as recording devices, which is helpful for purposes of telecardiology. There are many delivered by primary care physicians according to a controlled study of the treatment of hepatitis examples of successful telecardiology services C.56,57,58 Various specialties are contributing to worldwide. telemedicine, in varying degrees. In Pakistan three pilot projects in telemedicine Telecardiology59 was initiated by the Ministry of IT & Telecom, Government of Pakistan (MoIT) through the ECGs, or electrocardiographs, can be Electronic Government Directorate in transmitted using telephone and wireless. collaboration with Oratier Technologies (a

Telemedicine: A Review pioneer company within Pakistan dealing with mental health issues who present at rural healthcare and HMIS) and PakDataCom (a emergency departments in the network. bandwidth provider). Three hub stations were 4. Between 2007 and 2012, the University of linked via the Pak Sat-I communications Virginia Health System hosted a satellite, and four districts were linked with videoconferencing project that allowed child another hub. A 312 Kb link was also established psychiatry fellows to conduct approximately with remote sites and 1 Mbit/s bandwidth was 12,000 sessions with children and adolescents provided at each hub. Three hubs were living in rural parts of the State.62 established: the Mayo Hospital (the largest hospital in Asia), JPMC Karachi and Holy There are a growing number of HIPAA Family Rawalpindi. These 12 remote sites were compliant technologies for performing connected and on average of 1,500 patients telepsychiatry. There is an independent being treated per month per hub.59 comparison site of current technologies. Telepsychiatry60,61 Links for several sites related to telemedicine, telepsychiatry policy, guidelines, and Telepsychiatry, another aspect of telemedicine, networking are available at the website for the also utilizes videoconferencing for patients American Psychiatric Association.63,17 residing in underserved areas to access psychiatric services. It offers wide range of There has also been a recent trend towards services to the patients and providers, such as Video CBT sites with the recent endorsement consultation between the psychiatrists, and support of CBT by the National Health educational clinical programs, diagnosis and Service (NHS) in the United Kingdom. assessment, medication therapy management, In the United States, the American 60 and routine follow-up meetings. Telemedicine Association and the Center of As of 2011, the following are some of the model Telehealth and eHealth are the most respectable programs and projects which are deploying places to go for information about telemedicine. telepsychiatry in rural areas in the United States: The momentum of telemental health and 1. University of Colorado Health Sciences telepsychiatry is growing. In June 2012 the U.S. Center (UCHSC) supports two programs for Veterans Administration announced expansion American Indian and Alaskan Native of the successful telemental health pilot. Their populations target was for 200,000 cases in 2012.64 a. The Center for Native American Telehealth A growing number of HIPAA compliant and Tele-education (CNATT) and technologies are now available. There is an independent comparison site that provides a b. Telemental Health Treatment for American criteria based comparison of telemental health Indian Veterans with Post-traumatic Stress technologies.16 Disorder (PTSD) Teleradiology65 2. Military Psychiatry, Walter Reed Army Medical Center. Teleradiology is the ability to send radiographic images (x-rays, CT, MR, PET/CT, SPECT/CT, 3. In 2009, the South Carolina Department of MG, US...) from one location to another.16 For Mental Health established a partnership with the this process to be implemented, three essential University of South Carolina School of components are required, an image sending Medicine and the South Carolina Hospital station, a transmission network, and a receiving- Association to form a statewide telepsychiatry image review station. The most typical program that provides access to psychiatrists 16 implementation are two computers connected hours a day, 7 days a week, to treat patients with via the internet. The computer at the receiving end will need to have a high-quality display

Telemedicine: A Review screen that has been tested and cleared for for robotic telepathology systems and clinical purposes. Sometimes the receiving telepathology diagnostic networks.70 Dr. computer will have a printer so that images can Weinstein is known to many as the "father of be printed for convenience.65 telepathology".71 In Norway, Eide and Nordrum implemented the first sustainable clinical The teleradiology process begins at the image 72 sending station. The radiographic image and a telepathology service in 1989. This is still in modem or other connections are required for operation, decades later. A number of clinical this first step. The image is scanned and then telepathology services have benefited many thousands of patients in North America, Europe, sent via the network connection to the receiving 72 computer.65 and Asia. Today's high-speed broadband based internet Telepathology has been successfully used for enables the use of new technologies for many applications including the rendering teleradiology: the image reviewer can now have histopathology tissue diagnoses, at a distance, access to distant servers in order to view an for education, and for research. Although digital exam. Therefore, they do not need particular pathology imaging, including virtual workstations to view the images; a standard microscopy, is the mode of choice for Personal Computer (PC) and Digital Subscriber telepathology services in developed countries, analog telepathology imaging is still used for Line (DSL) connection is enough to reach 71 keosys central server. No particular software is patient services in some developing countries. necessary on the PC and the images can be Teledermatology73,74,75,76,77 65 reached from wherever in the world. Teledermatology is a subspecialty in the Teleradiology is the most popular use for medical field of dermatology and one of the telemedicine and accounts for at least 50% of all more common applications of telemedicine and telemedicine usage. e-health. In teledermatology, telecommunication Telepathology66 technologies are used to exchange medical information (concerning skin conditions and Telepathology is the practice of pathology at a tumours of the skin) over a distance using audio, distance. It uses telecommunications technology visual and data communication. to facilitate the transfer of image-rich pathology Teledermatology can reduce wait times by data between distant locations for the purposes allowing dermatologists to treat minor of diagnosis, education, and research.66,67 conditions online while serious conditions Performance of telepathology requires that a requiring immediate care are given priority for pathologist selects the video images for analysis appointments. Applications comprise health and the rendering diagnoses. The use of care management such as diagnoses, "television microscopy", the forerunner of consultation and treatment as well as telepathology, did not require that a pathologist (continuous) education. have physical or virtual "hands-on" involvement is the selection of microscopic fields-of-view for The dermatologists Perednia and Brown were analysis and diagnosis.66 the first to coin the term "teledermatology" in 1995. In a scientific publication, they described A pathologist, Ronald S. Weinstein, M.D., the value of a teledermatologic service in a rural coined the term "telepathology" in 1986. In an area underserved by dermatologists. editorial in a medical journal, Weinstein outlined the actions that would be needed to Teledentistry create remote pathology diagnostic services.68 Teledentistry is the use of information He, and his collaborators, published the first technology and telecommunications for dental scientific paper on robotic telepathology.69 care, consultation, education, and public Weinstein was also granted the first U.S. patents

Telemedicine: A Review awareness in the same manner as telehealth and requirements, including paying substantial telemedicine.77 licensure fees, passing additional oral and written examinations, and travelling for Teleaudiology interviews.81,82 Tele-audiology is the utilization of telehealth to Regulations concerning the practice of provide audiological services and may include 83 the full scope of audiological practice.78 telemedicine vary from state to state. Physicians who will be prescribing over the This term was first used by Dr. Gregg Givens in internet to patients should mandate strict 1999 in reference to a system being developed controls on their practice to insure that they stay at East Carolina University in North Carolina, compliant with the various State Medical Board USA. The first Internet audiological test was Regulations concerning internet prescribing.84 accomplished in 2000 by Givens, Balch and Keller. Advanced and Experimental Services The first Transatlantic teleaudiology test was Telesurgery performed in April 2009 when Dr. James Hall Remote surgery (also known as telesurgery) is tested a patient in South Africa from Dallas.78 the ability for a doctor to perform surgery on a Teleophthalmology57,79, 80 patient even though they are not physically in the same location. It is a form of telepresence. Teleophthalmology is a branch of telemedicine Remote surgery combines elements of robotics, that delivers eye care through digital medical cutting edge communication technology such as equipment and telecommunications technology. high-speed data connections and elements of Today, applications of teleophthalmology management information systems. While the encompass access to eye specialists for patients field of robotic surgery is fairly well established, in remote areas, ophthalmic disease screening, most of these robots are controlled by surgeons diagnosis and monitoring; as well as distant at the location of the surgery.84 learning. Teleophthalmology may help reduce disparities by providing remote, low-cost Remote surgery is essentially advanced screening tests such as diabetic retinopathy telecommuting for surgeons, where the physical distance between the surgeon and the patient is screening to low-income and uninsured patients. immaterial. It promises to allow the expertise of U.S. Licensing and Regulatory Issues specialized surgeons to be available to patients Restrictive licensure laws in the United States worldwide, without the need for patients to 84 require a practitioner to obtain a full license to travel beyond their local hospital. deliver telemedicine care across state lines. Enabling Technologies Typically, states with restrictive licensure laws also have several exceptions (varying from state Videotelephony to state) that may release an out-of-state Videotelephony comprises the technologies for practitioner from the additional burden of the reception and transmission of audio-video obtaining such a license. A number of states signals by users at different locations, for require practitioners who seek compensation to communication between people in real-time.85 frequently deliver interstate care to acquire a 81,82 At the dawn of the technology, videotelephony full license. also included image phones which would If a practitioner serves several states, obtaining exchange still images between units every few this license in each state could be an expensive seconds over conventional POTS-type telephone and time-consuming proposition. Even if the lines, essentially the same as slow scan TV practitioner never practices medicine face-to- systems.85 Currently videotelephony is face with a patient in another state, he/she still particularly useful to the deaf and speech- must meet a variety of other individual state impaired who can use them with sign language

Telemedicine: A Review and also with a video relay service, as well as to founding members. The first annual conference those with mobility issues or those who are of the society was held in Lucknow in the located in distant places and are in need of subsequent year and all the participants were telemedical or tele-educational services.85 inducted to the founding member group. In the following two years there was no scientific Health Information Technology activity till March 2005 when an International Health information technology (HIT) provides Conference on Telemedicine (INTELMED the umbrella framework to describe the 2005) was hosted by Indian Space Research comprehensive management of health Organization (ISRO) at Bangalore. During this information across computerized systems and its event a general body meeting was held among secure exchange between consumers, providers, the founding members present to resolve to government and quality entities, and insurers. form an interim executive body to initially take Health information technology (HIT) is in the responsibility of steering the activities of the general increasingly viewed as the most society till the formal registration of the society promising tool for improving the overall quality, and election of executive is held thereafter. safety and efficiency of the health delivery Unanimously the following interim group of system.86 Broad and consistent utilization of executive was formed; Dr S. S. Badrinath, HIT will: Chairman, Sankara Nethralaya (Founder  Improve health care quality; President), Sri Bhaskaranarayana of ISRO (Vice President), Prof. Saroj Mishra (Secretary) and  Prevent medical errors; Prof. K. Ganapathy (Joint Secretary-cum-  Reduce health care costs; Treasurer). Members of the executive body was selected from among representative of various  Increase administrative efficiencies ministries of Government supporting  Decrease paperwork; and telemedicine activities (Department of Information Technology & Indian Space  Expand access to affordable care. Research Organization), defense services, Interoperable HIT will improve individual academic organizations playing active role in patient care, but it will also bring many public telemedicine (AIIMS, New Delhi & SGPGI, health benefits including: Lucknow) and Indian office of WHO. The  Early detection of infectious disease society got formally registered in 2006 at outbreaks around the country; Lucknow having its registered office at telemedicine center, Sanjay Gandhi  Improved tracking of chronic disease Postgraduate Institute of Medical Sciences. management; and Considerable progress has been made over last  Evaluation of health care based on value few years. The society had its first, second, third enabled by the collection of de-identified and fourth annual conferences held at New price and quality information that can be Delhi (2006), Chennai (2007) and Chandigarh compared. (2008) respectively. The telemedicine society of 7,87 India, is now a reality. The international society Telemedicine in our Society for telemedicine and e-health, has now During the national conference on telemedicine recognized TSI as the official national society held in Lucknow in April 2001 the participants representing telemedicine activities in India. resolved to form a scientific society dedicated to Advantages of Satellite Communication88 telemedicine at national level and carry out annual scientific event pending a formal • Easy reach, quick installation registration, thus the telemedicine society of • No geographical and environmental barriers India was born and all the participants signed a resolution to this effect and are made the • Flexible, high quality network

Telemedicine: A Review • Extensive and Consistent geographic with 29 States and 6 Union Territories governed coverage by a federal system. Government-supported • Efficient support to broadcast and multipoint healthcare delivery follows a three tier system communications for medical education and and is primary responsibility of the state. There is no national health insurance policy. Almost consultation sessions 75% of the population resides in rural areas • Network capacity flexibility, reliability and lacking access to medical expertise and security infrastructure. Further, healthcare delivery is difficult in the Growth by Maximising the reach inhospitable geographical terrain like mountain

Pilot project in 2001, connecting : regions in the north-east, deserts of north-west Aragonda Apollo, Chennai & and the off-shore islands of Andaman and Chamaraj Nagar Narayana Hrudayalaya Lakshadweep. Telemedicine technology can bridge this divide by integrating this tool into the existing healthcare delivery system irrespective of socio-economic and geographical 2007 2006 disparities. 2005

2004 220 + nodes • Agencies like ISRO, Dept of IT, Railways, 2003 184 + nodes ( target 280 nodes) 2002 100 nodes 140 + nodes Few State governments, Private network by 58 nodes 148 - Remote 181 - Remote 2001 40 - Speciality 27 nodes 78 – Remote 109 - Remote 36 - Speciality Apollo, AHF, AIMS, ESCORTS etc are also 36 – Remote 22 - Speciality 31 - Speciality 5 nodes 17 – Remote 22 - Speciality part of this movement in their own 10 - Speciality 3 – Remote 91,92 2 - Speciality capacity. 10 Figure 5: ISRO Telemedicine network89 Many developments have taken place in the field of telemedicine as a result of contribution Minimising the Costs for Growth by both government and private sector to various activities. Initiatives taken by Ministries of Central Government of India (GoI)93 Department of Information Technology (DIT) Ministry of Communications and IT (MCIT): Some of the successful telemedicine 2002 projects implemented by DIT in various states 18 Lakhs 2003 2004 are telemedicine network in West Bengal for VSAT- 10 L 14 Lakhs 2005 2006 diagnosis and monitoring of tropical diseases TM system- 8 L 8.2 Lakhs 5 Lakhs ( S/W : 3 L) VSAT- 8 L 4 Lakhs TM system- 6 L and cancer care, Kerala and Tamilnadu VSAT- 5 L VSAT- 2 L ( S/W : 1.6 L) TM system - 3.2 L VSAT- 1.2 L TM system – 3 L TM system – 2.8 L Oncology network for facilitating cancer care ( S/W : 0 .65 L) ( S/W : 0.25 L) ( S/W : 0.25 L) 33% 40% 40% 20% and provision of specialty healthcare access in 11 rural areas of Punjab, Maharashtra, hilly state of Figure 6: System cost (Patient end per Himachal Pradesh and North-Eastern region. It 89,88 node) also established link among the three premier Telemedicine in India: Current Scenario and institutions viz. Sanjay Gandhi Postgraduate the Future90 Institute of Medical Sciences (SGPGIMS), Lucknow, All India Institute of Medical The triangular Indian peninsula holds every kind Sciences (AIIMS), New Delhi, Post Graduate of landscape spread over an area of 3 million sq Institute of Medical Sciences (PGIMER), km and having more than 1 billion population

Telemedicine: A Review Chandigarh which in turn connected to the state Beginning with ISRO’s Telemedicine pilot level hospitals. project of 2001, the telemedicine network in India has treated more than 25,000 patients. Indian Space Research Organization (ISRO) ISRO’s 2 satellite based Telemedicine network Presently, ISRO’s telemedicine network stretches to around 100 hospitals all over the via Indian Satellite System which started in 2001under GRAMSAT (rural satellite) program country with 78 remote/rural/district nowincludes 439 Hospitals-382 Remote/Rural hospitals/health centres connected to 22 District Hospitals/ Health Centres connected to specialty hospitals located in the major cities. 57 super specialty hospitals located in major Many states have come forward to introduce cities. Seventeen mobile telemedicine units are telemedicine on a regular operational basis and also part of this network.93 have planned to equip all the district hospitals ISRO’s Initiative in Telemedicine94 with telemedicine facility both for ambulatory & intensive care treatment. Karnataka, ISRO initiated Telemedicine programme in Chattisgarh, Kerala and Jarkand are some of the 2001 as a special programme, for providing; states which have initiated the establishment of • Telehealth to the un-served and the under- satellite based telemedicine facility for all their served district hospitals and a few trust hospitals. This will soon be followed by other states too. • Set up Telemedicine facilities in distant and rural of India to supplement the general As a result of ISRO’s telemedicine endeavour, healthcare infrastructure. remote areas like Kargil and Leh in the North, offshore islands of Andaman and Nicobar and 92,95 Efforts by ISRO Lakshwadeep, as well as some of the interior • Space based Rural Development parts of Orissa, Karnataka, Kerala, Chattisgarh, Programmes since 1990s J&K, North-eastern states of India and some tribal districts in certain other states have access • Major thrust for TM as a special programme to specialty healthcare from some of the major since 2001 specialty hospitals in the country today. • Spearheading the Telemedicine movement Continuing Medical Education96 in India with the largest network and continuous improvement Under ISRO’s telemedicine programme, Continuing Medical Education (CME) efforts provide doctors at rural healthcare centres a chance to upgrade their medical knowledge and skills through interactions with experts at the specialty hospitals through satellite based tele- link. Such interactions indirectly result in significantly enhancing the quality of healthcare available to rural patients. The Continuing Medical Education programme has been integrated with the tele-education programme by linking some of the medical institutions with the specialty hospitals and research centres. Mobile Telemedicine96

97 ‘Mobile Telemedicine Unit’ consisting of Figure 7: ISRO’s Telemedicine netwwork medical equipment along with telemedicine Telemedicine Initivatives96 hardware, software and VSAT system mounted

Telemedicine: A Review in a Bus/Van can establish a mobile Telemedicine for Special Situations96, 97 telemedicine centre at any place. Telemedicine connectivity has been provided The major area of mobile telemedicine every year since 2002 at Pampa, at the foothills applications are in the field of tele of Sabarimala shrine in Kerala where lakhs of ophthalmology and community health. Under pilgrims visit the shrine. Here the telemedicine mobile tele-ophthalmology, rural eye camps can connectivity is provided between the Temple be conducted and the rural population can Board Hospital at Pampa and Amrutha Institute undergo eye screening for cataract, glaucoma of Medical Sciences, Kochi and Trivandvam and diabetic retinopathy. Under community Medical College Hospital. health program, mobile telemedicine units are Several pilgrims availed the facility and some very useful not only for disease prevention but lives were saved. Similar efforts will be made also for health promotion in terms of running for other places also. awareness camps & teaching hygienic practices. Telemedicine during Tsunami Village Resource Centres and Telemedicine96 The ISRO’s telemedicine facilities at three Recently, ISRO has also initiated pilot projects hospitals – GB Pant Hospital, INHS for integrating Telemedicine/Tele-health with Dhanvantari at Port Blair, Andaman Island and the Resource Information database as well as Bishop Richardson Hospital at Car Nicobar Tele-Education facilities at the Village Resource along with ISRO Gramasat Network at 8 Islands Centres/Community Centres (VRC) to reach out was effectively used during post Tsunami to more rural areas of the country. The first of disaster relief work for the benefit of the remote the pilot projects has been implemented in the population of Andaman and Nicobar Islands. state of Tamil Nadu wherein the nodal centre More such telemedicine centres are being operated by an NGO agency at Chennai is planned at the primary health centres of various connected to remote villages in three districts islands of Andaman and Nicobar.96 and more are to come in the future. Ministry of Health & Family Welfare One of the major advantages of telemedicine (MoH&FW)97 technology has been the saving of cost and effort to the rural patients as they are not MoH&FW has implemented Integrated Disease required to travel long distances for obtaining Surveillance Programme network which connect consultation and treatment. A study conducted all district hospitals with medical colleges of the by an independent agency on one thousand state to facilitate tele-consultation, tele- patients in the Chamarajanagar district hospital education/ training of health professionals and in Karnataka has revealed that there was a cost monitoring disease trends. It has funded few saving of 81% to the patient. That is, the pilot national level tele-ophthalmology and rural patients who availed the telemedicine telemedicine projects. consultation and treatment spent only 19% of State Governments of various states of the money which they would have otherwise India96 spent if they had to travel to the nearest cities for a similar treatment. Various states, now realizing the advantages and benefits of telemedicine technology in modern In the case of remote offshore islands, this is day healthcare delivery, took initiatives to much more significant both to the patient and establish state wide telemedicine networks to the government administration. In such cases, strengthen the healthcare facilities in their not only the patients have the cost saving but states. The governments of Orissa and can be provided with quick and timely medical Uttarakhand have networked their secondary aid. level hospitals and then linked them to SGPGIMS, Lucknow for specialty consultation.

Telemedicine: A Review The Governments of Jammu and Kashmir, Tele-hospitals for rural access of specialty Chhattisgarh, Rajasthan, Karnataka, Jharkhand, healthcare services.96 Kerala with the support of ISRO and state of Global Telemedicine Projects initiated by Himachal Pradesh, Punjab, North Eastern states, Ministry of External Affairs, Government of West Bengal, Tamilnadu with the support of India98 DIT has established state wide network linking state Government Medical Colleges and district South Asian Association for Regional hospitals. Cooperation (SAARC) Telemedicine Network Academic Medical Institutions and The preparatory work for a pilot project Corporate Hospitals connecting one/two hospitals in each of the SAARC countries with the super specialty SGPGIMS, Lucknow a premier institution in hospitals that include AIIMS, New Delhi; public sector adopted IT in the form of hospital SGPGIMS, Lucknow; PGIMER Chandigarh information & management systems and started and CARE Hospital, Hyderabad of India. Jigme its telemedicine activities in 1999 with the Dorji Wangchuck National Referral Hospital, support of various government agencies. It has Thimphu, Bhutan and Indira Gandhi Child networked 24 national and international partner Hospital, Kabul, Afghanistan have been nodes and has been carrying out tele-education connected to SGPGIMS, Lucknow and and tele-healthcare activities and has developed 96 PGIMER, Chandigarh under this project for various modules for these activities. Two other tele-education and tele-healthcare activities.98 premier institutions of India viz. AIIMS, New Delhi (Jammu & Kashmir, Haryana, Orissa, Pan-African eNetwork Project North Eastern states network) and PGIMER, The MEA is implementing this project through Chandigarh and Sri Ramachandra Medical Telecommunications Consultants India Ltd. College and Research Institute , Chennai (35 (TCIL) to establish a VSAT based infrastructure nodes), Tata Memorial Hospital, Mumbai (30 for 53 African countries of the African union by nodes) Christian Medical College, Vellore are a satellite and fiber optic network that would also involved in similar activities. provide effective Tele-Education, Tele- In the corporate sector, the major players are Medicine, Internet, Videoconferencing and Apollo Hospital Group (64 nodes), AIMS (23 VoIP services. Ten super specialty hospitals in nodes), Kochi, Asia Heart Foundation (tele- India have been identified to provide telehealth cardiology & mobile van), Bangalore, Fortis services to 53 remote African hospitals.98 Hospital (27 nodes), Narayana Hrudayalaya (55 E-Learning in Health Sector99 nodes) and Escorts Heart Institute and Research Center (17 nodes). Sir Ganga Ram Hospital Online Open Access Bibliography (SGRH), New Delhi has launched its Two government agencies, National Informatics telemedicine centers in Haryana and Rajasthan Center (NIC) and Indian Council of Medical states. Research (ICMR), have established the Indian Mobile Telemedicine Medical Literature Analysis and Retrieval System (MEDLARS) Center to cater the With the support of ISRO, Shankar Nethralaya information needs of medical community of at Chennai, Meenakshi Eye Mission and India.99 Aravind Eye Hospital Madurai and four other corporate eye hospitals have launched Mobile Collaborative Knowledge Sharing through Tele-ophthalmology service for early diagnosis Telemedicine Network and treatment of ophthalmic diseases under Premier academic medical institutions of India National Blindness Control Program. SGRH, are actively involved in sharing their academic AIMS, SRMC, and AHF have launched mobile activities over the telemedicine network.99

Telemedicine: A Review National Digital Medical Library Consortium each of which will be connected to medical National Medical Library’s Electronic colleges (Nodes) in that region. One of these Resources in Medicine (ERMED) Consortium is regional hubs will be identified as the Central an initiative taken by Director General of Heath Hub which will be overall responsible to co- ordinate the National Network in addition to Services (DGHS) to develop nationwide electronic information resources in the field of provide infrastructure for Central Content medicine. 76 centrally funded Government Development Centre. DIT is putting efforts in Institutions including 10 under DGHS, 28 developing School of Telemedicine and laboratories of Indian Council of Medical Biomedical Informatics into National Resource Research and AIIMS libraries are selected at the Center for telemedicine. It is planning to launch various other projects in collaboration with initial stage as its core members. The MoH&FW aims to provide fund required for the purchase other government organizations such as of electronic journals under this consortium Development of a Web Based Telemedicine project.99 System for chronic diseases, E-Health visualization and E-Health associated field, Medvarsity advanced ICT for health care proof of concept Apollo Hospitals Group in association with project in district by NIC state center, NIIT Ltd has launched Medvarsity to provide Hyderabad and access to quality healthcare in the platform for online delivery of continuing Tamil Nadu through a pilot telemedicine medical education and offer variety of courses network. National Knowledge Commission for doctors, nurses and other paramedical which is a high-level advisory body to the Prime personnel.99 Minister of India, with the objective of transforming India into a knowledge society, are Future Perspective of Telemedicine in planning to develop Indian Health Information 99,100 India Network.100 The GoI is planning and implementing various The Future ISRO’s telemedicine endeavour is national level telemedicine projects and expanding its outreach and has the potential to deploying mobile and fixed tele-centers within open up new frontiers for facilitating rural the country to provide health care facilities to healthcare in India. the remotest and poorly accessible areas of the country. ISRO’ telemedicine nodes are Encouraged by the steady growth of its expanding and are also planning to launch telemedicine programme, ISRO has also dedicated satellite HEALTHSAT for healthcare envisioned the development of delivery. Encouraged by the success of Kerela “HEALTHSAT”, an exclusive satellite for ONCONET project by DIT, MoH & FW is meeting the healthcare and medical education planning to implement ‘OncoNET India’ project needs of the country at large. This satellite, which will network 27 Regional Cancer Centres when deployed along with wireless and with 100 Peripheral Cancer Centers to facilitate terrestrial communication links, can bring a National Cancer Control Program and ‘National large change in augmenting the present Rural Telemedicine Network (NRTN)’ project healthcare delivery system in the country. Due under National Rural Health Mission. Another to the untiring efforts of various departments project in the field of e-learning is ‘National like the Department of Space and the Medical College Network Project’ to establish a Department of Information Technology, State national grid of telemedicine for networking of Governments, NGOs and Private and Corporate medical colleges. Few tertiary care academic Hospitals/Agencies, the majority of the rural medical institutes from different regions of the population all over the country will stand to country will be identified as Medical benefit from telemedicine technology that can Knowledge Resource Centres (Regional Hub), usher in a revolution for transforming the face of healthcare in India.100

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