Telemedicine in India-the Apollo experience: 

 
Dr. K. Ganapathy,   
Neurosurgeon, Apollo Hospitals,  Chennai , India.

“ 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 centers. 

Introduction:

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 

What is Telemedicine?

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 specialities?  

The following table indicates the ground realities of the present state of health care in India.

 Health Scenario in India:

620 million live in rural India (NCAER)

Bed-Population 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 encompass?  

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 conducted remotely. 

What are the advantages of telemedicine?   

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 help provide a physician where there was none before.

 INDIA

–THE LAND OF THE FUTURE ! 

65% of 1100 million will be literate by 2005

60% of rural India has access to TV coverage.

60% 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 Telemedicine.

The following tables give some important facts which have to be considered when introducing Telemedicine in India.

 Advantages 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 and Teleconsultant,

International grand rounds, Web casting conferences,

Motivation for ­­ 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:

Will 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 console,

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 Teleconsultation

     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 agencies like  WHO, World Bank, Asian Development Bank, Govt of India etc.

Successful implementation in India = Successful Implementation anywhere in the world

 

 Pilot study:

To evaluate  acceptance– patient, GP, Teleconsultant, public, Govt.

Identification of disciplines / diseases for teleconsultation.

Designing appropriate need based cost effective modules.

Training technical personnel, GP, Teleconsultant.

Techno economic feasibility, optimum pricing.

Limitations of Teleconsultation.

 

 

   

The Aragonda (Andhra) Story:  

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.  

The Sriharikota Story:  

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. 

Expansion Plans:  

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 Conferencing:  

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 Intercontinental 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  of 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.

This will considerably augment the skills of all those who take part and more important change  our perspectives and help us think

globally.  Tele conference between Apollo, Chennai & Fujitha university, Japan
     

Conclusion:

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 technological barriers, insurmountable 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 Healthcare”.   

 
 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 


 

from Peer Reviewed Resources only

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