Care from the air: Telemedicine in India

The Indian healthcare industry has been exposed to various flavors of “telemedicine”, from the healthcare portal suggesting that healthcare info provided on the website uses telecommunications to provide healthcare information to patients, thus delivering ‘tele health’, to video conferencing vendors who claim to be “telemedicine” providers . At the other end there are a few genuine healthcare providers who really use telemedicine effective to provide care, minus the hype, and organizations such as ISRO which are taking an innovative approach to facilitate healthcare delivery by way of launching an exclusive health satellite. To the mind of many healthcare stakeholders there is still confusion on what really comprises telemedicine.

What is Telemedicine?

According to a Japanese definition in 1996, “it the use of any electrical signal to transmit medical information”….


In a JAMA paper in 1995 Telemedicine has been defined “as the use of telecommunications to provide medical information and services. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at facilities in two countries, using videoconferencing equipment”.

A broader definition from University of Virginia is “the use of telecommunication technology to deliver healthcare services and health education to sites that are distant to the host site or educator”

The American College of Radiology has however defined the detailed ACR standard for Teleradiology, which includes definition of teleradiology, besides goals, qualifications, qualification of personnel, equipment guidelines, licensing, communication, quality control.

Applications

Clinical applications could be utilized in the following areas effectively, though one could argue that telemedicine could be used for any specialty.

Cardiology
Radiology
Homecare
Pathology
Endoscopy
Nephrology
Ophthalmology
Surgery
Emergency care

Many of these have specific applications and interfaces built around these specialties, which differentiate them from generic telemedicine applications.

Telemedicine worldwide

The history of telemedicine dates back to 1971, when the Alaska Biomedical Demonstration Project linked 26 sites using NASA satellite technologies. The Nebraska Psychiatric Institute is mentioned as the pioneer in some papers citing the use of closed circuit television in 1955 as “telemedicine”. In 1967, Mass Gen linked up to Logan airport using 2 way audiovisual microwave circuit. The developed world has made major strides in utilizing telemedicine for healthcare delivery.

Telemedicine in India: the drivers

The drivers for adoption of telemedicine could vary from country to country based on various factors. Some of the factors that would expedite the telemedicine revolution in India are:

Topography

Think of a patient in Tinsukiya, Assam or Aragonda, Andhra Pradesh who requires a consultation with a specialist at Bangalore or Mumbai. The cost of travel and the travel it self could be a deterrent to the poor patient in these rural settings. Even if a specialist is available at the nearest town, reaching the interiors of such a far flung village would be a challenge. This is where telemedicine could be utilized as an effective medium for healthcare delivery. India with a diverse collection of landscapes with mountains and valleys and high altitudes, telemedicine could well be a boon for the patients.

Travel Time /Cost

There is a shortage of specialist/ super specialist professionals in India, especially in rural areas. It might not be good time management on the part of the specialist to travel all the way to the rural areas without having enough patients to be attended to there. Travel time can be cut down dramatically while the expertise is made available in real time via technology. The specialist’s physical presence becomes necessary only when a surgical procedure is planned. In reality even surgical procedures are being conducted with guidance from the specialist who is at a remote location. For a patient cost of travel is a major worry especially if she has to fly in to a specialist care center in a city.

Pressure to reduce costs

Cost of healthcare and questions on who will bear the burden of care are issues across the world, developed countries included. The incidental expenses related to patient care, i.e. the cost associated with factors other than the actual medial care such as travel, accommodation for relatives, food etc also contribute substantially to the cost of treatment. In a country where health insurance is yet to catch up, cost of acre is borne by patients, in many cases by selling property and livestock. If hospitals can reduce these costs associated with treatment it would go a long way in reducing the burden of care on the patient. Telemedicine seems to the answer.

Availability of healthcare facility/ Transportation

It is no understatement if I say that healthcare delivery in rural India is not adequate. The government has limitations and so does private enterprise. Setting up a full fledged care facility at a remote location might not always be economically or operationally viable. Even if there is a healthcare facility with bare minimum resources, transportation might be a challenge. Various studies have documented the inverse relationship between distance and outcomes particularly in Acute MI and Ventricular Arrhythmias.

Training

Telemedicine is an effective medium to impart knowledge to professionals within a healthcare organization. This becomes relevant in corporate hospitals chains spread across the country wherein they could share and institutionalize best practices across the group. Telemedicine could also be utilized to provide public health education to the remote corners of India.

Telemedicine for Competitive Advantage

Telemedicine is a technology enabled marketing tool as well. It makes it possible for hospitals to address the needs of patients who might not have otherwise used their services. Slowly by steadily telemedicine is being utilized as a tool for competitive advantage, which would over a period of time, lead to a divide in the healthcare industry along the lines of “telemedicine haves and have nots”.

The players:

The two major players in the Telemedicine space in India are Apollo Hospitals and Asia Heart Foundation. Between the two, several remote villages have realized the benefits of technology enabled care. The organizations are now in a position to share the expertise available in in-house with neighboring countries too. The missionary zeal with which these hospitals operate will ensure that distance will not be a deterrent to patient care. The public sector too is taking steps in this direction. According to Dr. Alok Roy, Asia Heart Foundation, several lives were saved by telemedicine intervention in far flung villages, which might not have been otherwise possible.

Issues:

Beneath the glossy reports of telemedicine successes, there are many stories of hard work, dedication which happen behind the scenes to make this all happen. Making Telemedicine work is not as sweet as the reports. Some of the issues involved are outlined below:

Connectivity

Connectivity for Telemedicine is a major concern as many of the remotes villages do not have basic telephony. Thus an exclusive satellite from ISRO to service healthcare needs is revolutionary and will change the dynamics of telemedicine in India very soon. Satellites provide almost 100 percent uptime, making it the best medium for countries such as India with diversity in terrain. The bandwidth available with various connectivity options are provided below.

POTS – 20 kbps
ISDN – 128 Kbps
T1 - 1.54 Mbps
Cable modem – 1- 27 Mbps
T3 – 44 Mbps
ATM - 155 Mbps
Small Foot print Satellite Dish – 400 kbps
Low orbiting Satellite
Asynchronous: – 6 mbps
Synchronous: 14 kbps – 2 Mbps

Wireless Terrestrial: 1- 26 Mbps


Standards

As Telemedicine becomes ubiquitous, a challenge to be addressed is adherence to standards. A few years down the line, when corporate mergers and acquisitions become commonplace in the healthcare sector integrating to leverage investments made be a major roadblock to integrating services. Integrating disparate systems could be expensive in the long term, unless standards are followed from day one. HL7 and DICOM are two standards that are critical for the success of Telemedicine in India.


Security & Privacy

Security and Privacy are no serious concern in India at the moment as consumerism in healthcare is yet to take the proportions in the developed world. However this is set to change soon. As patients become more aware, thanks to the Net, these concerns will have to be addressed. European and US standards for Privacy and Security are being incorporated by vendors in those countries.

IHE

Integrating the Healthcare Enterprise initiative is a US initiative by leading trade organizations in the US. The role of IHE is the integration of healthcare information, promotion of existing standards ( eg HL7, DICOM, CORBA, XML) and implementation profiles for transactions used to communicate images and patient data within Hospital Information systems Radiology Information systems ( RIS) and Picture Archiving and communication systems ( PACS). These initiatives will make the move towards a Telemedicine enabled Electronic Health Record.

Legal & regulatory

Who is liable is a Tele medicine assisted remote surgery ends in a disaster due to loss of connectivity? The surgeon? The Satellite provider? The software/hardware provider? What is the legal status of a telemedicine based diagnosis in a medico legal framework? Many of thee questions have not been raised in India as we are still in the honey moon phase of Telemedicine, when all news is good news.


Management Issues

Strange as it may sound the major areas of concern in Telemedicine implementation is not technology perse, but the organization’s preparedness to handle the management and human resources issues related to the same. Telemedicine is a labor intensive process which involves co ordination with sending and receiving stations and the staff technical, clinical and support staff at the centers. Management buy in is slow in most organizations. Training the doctors, nurses and technicians on a continuous basis is critical, more so as employees turn over is increasing in the healthcare setting. The success definitely depends on the management’s commitment to a long-term strategy to achieve competitive advantage utilizing telemedicine.