“ Watson, come here I want you” said
Alexander Graham Bell on March 20, 1876, when he inadvertently spilled
battery acid on himself, while making the world’s first telephone call.
Little did Bell realize that this was indeed the world’s first telemedical
consultation. We have come a long way since then. Today even tele surgery
is a reality. This article will briefly review some aspects of
Telemedicine particularly its relevance in a developing country like India
and the experience of the Apollo Hospitals in setting up telemedicine
Secondary and tertiary
medical expertise is not available in several areas of the world. Quite
often, many patients are sent elsewhere at considerable expense. In a
number of these cases the treatment could have been carried out by the
local doctor with advice from a specialist. Even within a country there is
a tendency for specialists to concentrate in the big cities making medical
care in suburban and rural areas sub optimal Using a PC, a scanner, a
digital camera networking, appropriate software and telecommunications it
will be possible to transfer clinical data from any part of the world to
any other part.
Offering medical advice remotely, using
state of the art telecommunication tools is now a regular feature in
several parts of the world. Several studies have shown telemedicine
to be practical, safe and cost effective.. Telemedicine hinges on transfer
of text, reports, voice, images and video, between geographically
separated locations Success relates to the efficiency and effectiveness of
the transfer of information
Telemedicine is a method,
by which patients can be examined, investigated, monitored and treated,
with the patient and the doctor located in different places. Tele is a
Greek word meaning “distance “and Mederi is a Latin word meaning, “to
heal”. Time magazine called Telemedicine “healing by wire”. Though
initially considered “futuristic” and “experimental” Telemedicine is today
a reality and has come to stay. In Telemedicine one transfers the
expertise, not the patient. Hospitals of the future will drain patients
from all over the world without geographical limitations. In Cyberia after
all one is a netizen! High quality medical services can be brought to the
patient, rather than transporting the patient to distant and expensive
tertiary care centres. A major goal of telemedicine is to eliminate
unnecessary travelling of patients and their escorts. Image acquisition,
image storage, image display and processing, and image transfer represent
the basis of telemedicine. Telemedicine is becoming an integral part of
health care services in several countries including the UK, USA, Canada,
Italy, Germany, Japan, Greece, and Norway and now in India.
What is the relevance of
telemedicine in a developing country like India and particularly in the
The following table indicates the ground realities of the
present state of health care in India.
Scenario in India:
620 million live
in rural India (NCAER)
ratio 1:1333 (1991) Vs. ideal of 1:500
2 million beds
are required as against0.7 million available.
700 hospitals of
250 beds each are required every year.
only 9% of 1
billion people are covered health schemes.
only 0.9% of GDP
for health (WHO recommends 5%)
5% of annual
family income spent towards curative health care.
Specialists relocating to sub-urban or rural areas
In Utopia, every citizen has immediate
access to the appropriate specialist for medical consultation. In the real
world 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 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 practice in suburban
areas have failed. After all professional isolation would lead to
mediocrity, which is one step away from entering the Jurassic Park.
‘Health for All’ may be a slogan even in 2020.
It is generally considered that
communities most likely to benefit from telemedicine are those least
likely to afford it or have the requisite communication infrastructure.
This may no longer be true. In contrast
to the bleak scenario in health care, computer literacy is fast
developing. Prices are falling. Health care providers are now looking at
Telemedicine as their newly found Avathar. 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 realised that the future of telecommunications lies in
satellite-based technology and fiber optic cables. Providing health care
in remote areas using hi tech is not as absurd as it may initially appear.
Could even the greatest optimist, have anticipated the phenomenal
explosion in the use of computers, in India.
What does telemedicine
Telemedicine covers a wide
range of activities. In the past it was primarily teleradiology – the
transferring of high resolution medical images, X ray pictures,
ultrasound, CT, MRl pictures, live transmission of ECGs and
echocardiograms. Today even a detailed clinical examination can be
What are the advantages of
Worldwide there is
difficulty in retaining specialists in non-urban areas. The distribution
of specialists in India is indeed lopsided. There are more neurologists
and neurosurgeons in Chennai, than in all the states of North eastern
India put together.
Similarly tertiary care
hospitals are also concentrated in pockets with large segments of the
population having no access. The increasing availability of excellent
telecommunications, infrastructure and video conferencing equipment will
a physician where there was
LAND OF THE FUTURE !
65% of 1100 million will be literate by 2005
of rural India has access to TV coverage.
of rural India has access to TV coverage.
650,000 existing PCOs ® internet kiosks,.
400,000 villages already have telephone connections.
Internet users in India 2m Dec 2001, 8.5m 2003.
Hardware, software and brain ware all available.
Telemedicine can thus avoid
unnecessary travel and expense for the patient and the family improve
outcomes and even save lives. Once the “virtual presence” of the
specialist is acknowledged, a patient can access resources in a tertiary
referral centre without the constraints of distance. Telemedicine allows
patients to stay at home ensuring much needed family support. In a large
Telemedicine project in the USA 83% of patients who would have been
transferred to an urban hospital remained in their community reducing the
cost by at least 40 to 50%. This also ensures maximal utilisation of
suburban hospitals. The general practitioner in the rural/suburban area
often feels that he would loose his patient to the city consultant. With
Telemedicine the community doctor continues to primarily treat the patient
under a specialist’s umbrella. With modern software/ hardware at either
end 90% of the normal interaction can be accomplished through
The following tables give
some important facts which have to be considered when introducing
Telemedicine in India.
of telemedicine in India:
Doctors licensed to practice all over India,
Maximum utilisation of limited resourcesSaves travel, time and money,
Makes Geography History!!
Enormous CME potential for GP, urban trainee
International grand rounds, Web casting conferences,
computer literacy among doctors
In unnecessary referrals to specialists,
Useful in designing credits for re certification of doctors.
Points to be addressed in implementing TM project:
faster transmission or better image quality alter
diagnosis or treatment ?
Medical Coordinators for each specialty to lay ground rules,
Technical coordinators to identify the most effective mode of
data acquisition, compression, transfer and manipulation at TC’s
Execution of pilot project within 6 months,
Collecting data over 1 year and analyzing data over next 3 months.
Implementation of telemedicine in India:
With software, hardware, brain ware and a large number of doctors
licensed to practice abroad, India could offer global
at reduced international rates.
Sophisticated extension of medical transcription.
Marginal profits for Teleconsultation in the metros.
TM for suburban and rural India heavily subsidised from
WHO, World Bank, Asian Development Bank, Govt of India
Successful implementation in India = Successful
Implementation anywhere in the world
evaluate acceptance– patient, GP, Teleconsultant, public, Govt.
disciplines / diseases for teleconsultation.
Designing appropriate need based cost effective modules.
Training technical personnel, GP, Teleconsultant.
Techno economic feasibility, optimum pricing.
Limitations of Teleconsultation.
As in several disciplines,
the Apollo Hospitals have been the pioneers in putting up the first modern
secondary care rural hospital using Telemedicine to provide expert care.
As a pilot project a secondary level hospital was set up in a village
called Aragonda 16km from Chitoor (population 5000). This 40 bedded
hospital was equipped with a CT scan, a modern ultrasound, ECHO, automated
laboratory equipment, an incubator, automated ECG etc. A paediatrician, a
general physician and a general surgeon were available in addition to
general duty doctors.
Starting from simple web
cameras and ISDN telephone lines today the village hospital has a state of
the art video conferencing system and a VSAT (Very Small Aperture
Terminal) satellite installed by ISRO (Indian Space Research
Organisation). About 200 tele consultations have been given to this
village alone from specialists and super specialists from Chennai. A
specially designed software (Mediscope) was used and the clinical history
and physical findings transferred from Aragonda. . Images of x rays and
ultrasound were scanned; compressed and sent thro ISDN lines (64 x6
384kbps). CT images being DICOM compatible were directly electronically
transferred to the telemedicine computer for onward transmission to
Chennai. Most of the teleconsultations were initially off line – store and
forward. The tele consultant’s opinion was sent back to the primary
physician. There are no fixed hours for tele consultation – a medical
officer being available at the telemedicine unit at Chennai from 9am to
5pm. Arrangements are now being made to provide emergency tele
consultation as well. When the tele consultant wanted to directly
interact with the primary physician and the patient, a “net meeting” was
initially arranged. Later on with availability of better infrastructure a
formal video conference was held using state of the art video conferencing
equipment. . All such on line interactions were recorded and stored.
Detailed clinical “examination” of pseudo seizures, involuntary movements,
Parkinsonism, myopathy etc. was possible. Soon an electronic digital
stethoscope will be made available so that auscultation of the heart and
lungs can also be done remotely. In almost all cases the tele consultant
was able to give a definite opinion and guide the local physician.
Several serious head injuries not requiring surgery were successfully
managed in the village hospital.
Some cases required
management in a tertiary care hospital. Details of the treatment were
discussed in detail with the patient and the family so that they were well
informed and fully prepared. These tele discussions were of considerable
help. Tele consultation was particularly useful in the follow up of
already treated patients. Interestingly the acceptance of tele
consultation by the rural patient, the sub urban doctor and the suburban
community was much better than expected. None of them were really averse
to a tele consultation. The tele consultants have also accepted this new
method of interacting with a patient. Detailed evaluation of the socio
economic benefits needs to be done.
Sriharikota Space Center is
an important launch pad of the Indian Space Research Organsiation located
130 kms from Chennai. It is actually an island. About families live in
the campus. The Health Center also provides medical assistance to the
neighbouring villages Unlike Aragonda here a virtual OP is operational
every Saturday from 10am to 1pm. 25 different specialities are covered
some every week, others once a fortnight and others once a month.
Emergency consultations on other days are also available.
It is proposed to establish
a VSAT telemedicine link up with Port Blair in the Andaman and Nicobar
Islands soon. Connectivity has already been established with Information
Centres at Gauhathi and Calcutta. The tertiary care hospitals at
Hyderabad, Delhi and Madurai are interconnected. Tele consultation is also
available to doctors in the Middle East and other countries. Connectivity
with the Apollo Hospitals at Colombo, Dhaka, Bilaspur, Erode and others
are on the anvil.
Other uses of Video
The Telemedicine department of the Apollo hospitals was the
only unit from Asia which took part in the Ist Arab International
conference on Telemedicine in January 2001. Subsequently a paper was
presented from Chennai, at an International conference on telemedicine at
Upsaala Sweden in June 2001. This was an
Live multipoint Symposium between
Europe, Africa, Asia, Australia and Americas
on the topic.
“Telemedicine as a tool for a more equitable distribution
Of health care delivery around the world”
Video conferencing is an inexpensive way
projecting the state of the art facilities available in India to a
global audience. In August 2001 the Dept of Neurosurgery Apollo
Hospitals Chennai had a two hour teleconference with the Dept of
Neurosurgery Fujitha Health University, Nagoya Japan.This
international grand round went of without a hitch. Regular conferences
such as this are planned to be conducted periodically.
will considerably augment the skills of all those who take part and
more important change our perspectives and help us think
conference between Apollo, Chennai & Fujitha university, Japan
It is our dream that
within the next few years there will be telemedicine kiosks throughout
the length and breadth of suburban and rural India. No Indian should
be deprived of a specialist consultation wherever he/she is. This is
not impossible. What is required is not implementing better technology
and getting funds but changing the mind set of the people involved.
The first generation of
telemedicine enthusiasts should not forget that technology should be
used as a support to treat patients and not viewed as a goal in
itself. The challenge today is not confined to overcoming
though they may appear.
It is true that available
technology still has considerable scope for improvement. Rather the
challenge is why, where and how, to implement which technology and at what
cost. A needs assessment is critical. Due to pressure from powerful
vendors the perceived needs for Telemedicine may not conform to the actual
needs. The take off problems, facing telemedicine is legion. Telemedicine
today sounds hep and cool, but the reality may be quite different. The
future however promises to be exciting. So ladies and gentlemen hang on
for the ride! Telemedicine will be more than a roller coaster trip. The
journey will well be worth the wait.
Time alone will tell
whether Telemedicine is a “forward step in a backward direction” or to
paraphrase Neil Armstrong “one small step for IT but one giant leap for