national rural telemedicine network for india- mohfw

National Rural Telemedicine Network

National Rural Telemedicine NetworkSuggested Architecture and GuidelinesDraft Proposal Version 1.0

Ministry of Health & Family Welfare

Government of IndiaContent31.Executive Summary

32.Introduction

33.Background

44.Current Scenario

65.Scope of the Project

66.Expected Benefits

77.Proposed Guidelines / Framework for Indian Rural Telemedicine Network

77.1.Defining a National Rural Telemedicine Network

87.2.Standardization First Step Towards National Rural Telemedicine Network

87.3.Constituents of Telemedicine Network

87.3.1.LEVEL-1: Primary Health Center (PHC) / Community Health Center (CHC) / Village Unit

87.3.2.LEVEL-2: District Hospital

97.3.3.LEVEL-3: State Hospital / National Super Specialty Hospital

97.3.4.LEVEL-M: Mobile Telemedicine Unit *

107.3.5.NRHM Smart Card

107.4.Process and Infrastructure Guidelines at Different Layers of Hierarchy

107.4.1.Telemedicine Process for LEVEL-M and LEVEL-1 units

117.4.2.Telemedicine Process for LEVEL-2 and LEVEL-3 units

127.4.3.Telemedicine Hardware / Software Requirement at LEVEL-M and LEVEL-1

137.4.4.Telemedicine Hardware / Software Requirement at LEVEL-2

147.4.5.Telemedicine Hardware / Software Requirement at LEVEL-3

167.5.Proposed Organizational Plan

167.5.1.Preparation of Infrastructure, E-Health Education and Training

167.5.2.Setting Guidelines for Administration and Clinical, Educational and Governance Telemedicine Practices

167.5.3.Identification of Vendor for Project Implementation

177.5.4.Recruitment of Technical / Medical Manpower

177.5.5.Installation of Equipments, Network Media, Testing, Training and Hand-Holding

177.5.6.Periodic Monitoring and Preparation of Interim Report

177.5.7.Impact Evaluation at the End of Each Year and After Five Year

188.Budget requirement

188.1.Financial Requirement for Phase-I

188.2.LEVEL-1 (PHC / CHC / Village) Units

208.3.LEVEL-M (Mobile Telemedicine Van)

228.4.LEVEL-2 (District Hospitals)

248.5.LEVEL-3 (State Hospital /Super Specialist Hospitals)

268.6.Financial Summary

1. Executive Summary

2. IntroductionIndia is the second most populous country of the world and has changing socio-political-demographic and morbidity patterns that have been drawing global attention in recent years. Despite several growth-orientated policies adopted by the government, the widening economic, regional and gender disparities are posing challenges for the health sector. About 75% of health infrastructure, medical man power and other health resources are concentrated in urban areas where 27% of the populations live. Contagious, infectious and waterborne diseases such as diarrhea, amoebiasis, typhoid, infectious hepatitis, worm infestations, measles, malaria, tuberculosis, whooping cough, respiratory infections, pneumonia and reproductive tract infections dominate the morbidity pattern, especially in rural areas. However, non-communicable diseases such as cancer, blindness, mental illness, hypertension, cardio vascular disorders, diabetes, HIV/AIDS, accidents and injuries are also on the rise. The health status of Indians, is still a cause for grave concern, especially that of the rural population. This is reflected in the life expectancy (63 years), infant mortality rate (80/1000 live births), maternal mortality rate (438/100 000 live births); however, over a period some progress has been made. To improve the prevailing situation, the problem of rural health is to be addressed at both macro (national and state) and micro (district and regional) levels. This is to be done in a holistic way, with a genuine effort to bring the poorest of the population to the centre of the fiscal policies. A paradigm shift from the current 'biomedical model' to a 'socio-cultural model', which should bridge the gaps and improve quality of rural life, is the current need. A revised National Health Policy addressing the prevailing inequalities, and working towards promoting a long-term perspective plan, mainly for rural health, is imperative. Recent launch of National Rural Health Mission (NHRM) by the Ministry of Health & Family Welfare is a step in this direction.

3. Background

India lives in its villages, so said Mahatma Gandhi, Father of the Nation, but the country today, after 60 years of independence, is characterized by low penetration of healthcare services to its village population. Even though there have been several initiatives taken by both the Government and the Private sector, the rural and remote areas continue to suffer from absence of quality healthcare services. The health indicators of the nation are in dismal situation even after implementation of several nationwide projects to improve it. Recently, the union government has adopted a mission approach to boost the public health for the masses by launching National Rural Health Mission (NRHM). One of the objectives of the NRHM is to provide the rural population access to healthcare services. In this context, Telemedicine, an information and communication technology based tool, has the potential to assist in electronic delivery of diagnostic and healthcare services to remote rural population even in the absence of physical infrastructure in place thus can create a platform to network India. Telemedicine helps to provide healthcare where there is none and improve healthcare where there is some.The fact is that while 70% of our population lives in rural India; 90% of secondary & tertiary care facilities are in the cities and towns far away from the rural India. At the same time, it is also a fact that a significant proportion of patients in these remote locations could be successfully managed with some advice and guidance from specialists and super-specialists in the cities and towns. This is the power of Telemedicine. It is no surprise that Telemedicine is playing an increasingly important role in not only providing diagnostic and consultation services but also in facilitating Tele-education and training of personnel across the country.4. Current Scenario

A number of initiatives are underway in the area of telemedicine with the objective for providing quality consultation and caring for patients in areas where specialized patient care is not available. Although telemedicine implementation remains in its infancy, interest and activity appears to be growing to provide consultation of a Super-specialty doctor from a distance through videoconferencing along with exchange of medical records online. In addition to major support and thrust provided by DIT through projects and systems, organizations like ISRO, reputed academic medical institutions like SGPGI, AIIMS, PGIMER, AIMS, SRMC and corporate hospitals like Asia Heart Foundation, Apollo Hospitals, SGRH, Fortis, Max etc. have taken and continuing to take significant initiatives for installation of telemedicine systems at different parts of the country.

The Department of Information Technology (under MCIT) has taken a pivotal role in defining and shaping the future of Telemedicine application in India. Backed by a strong vision to build a national Telemedicine Network in India, DIT has been involved at multiple levels this includes Development of Technology, Initiation of pilot schemes and standardization of Telemedicine in the country. Some of these are briefly described below.

DIT has funded development of Telemedicine software systems- the prominent ones being Mercury and Sanjeevani software by C-DAC. DIT has also sponsored the telemedicine project connecting three premier medical institutions- viz. SGPGI, Lucknow, AIIMS, New Delhi, and PGIMER, Chandigarh- using ISDN connectivity. These hospitals as in turn connected to other state level hospitals.DIT Implemented Tele-medicine foe Diagnosis & Monitoring of tropical diseases in West Bengal using low speed WAN, developed by Webel (Kolkata), IIT, Kharagpur and School of Tropical Medicine, Kolkata. The system has been installed in School of Tropical Medicine Kolkata and two District Hospitals.

Similarly, DIT has funded establishment of an Oncology Network for providing Telemedicine services in cancer detection, treatment, pain relief, patient follow-up and continuity of care in peripheral hospitals (nodal centers) of RCC. The project was implemented by C-DAC, Trivandrum and Regional Cancer Center (RCC), Trivandrum. The Kerala OncoNET model has been replicated by DIT at RCC, Adiyar in Chennai with C-DACs Mercury Telemedicine Solution. Success of the cancer network in Kerala has been adopted by the Ministry of Health & Family Welfare, Government of India to take major step towards launching National Cancer Care Network.Also projects on setting up of telemedicine facilities at two referral hospitals and four District hospitals using West Bengal State Wide area network of 2 Mbps, and setting up Telemedicine and Tele-education (continuing Medical Education ) facilities in Kerala connecting Regional Cancer Center (RCC), Sri Chitra Thirunal Institute of Medical Sciences(SCTIMST), Medical College Hospital (MCH) and Trivandrum Medical College (TMC). Trivandrum with four hospitals at Taluk and District level using ISDN connectivity is implemented with C-DACs Mercury Telemedicine Solution.

Several state level Telemedicine network like Kerala state Telemedicine Network, Tamilnadu state Telemedicine Network, Haryana & Panjab state Telemedicine Network, etc. are coming up as pilot project and have shown promising results.

In addition, three state capital district level hospitals in north eastern states of India are getting connected with super- specialty hospitals, one at Kohima, Nagaland already being operational. Another one linking one each state level hospital in Sikkim and Mizoram with Indraprastha Apollo Hospital is example of Public-Private Telemedicine Network in place and under effective use.In a short span of time, some significant progress has been achieved in the field of Telemedicine in India. However, there is still a long way to go. While there are over 20,000 PHCs providing primary care services in the rural areas, and about 500 district hospitals, Telemedicine has reached to about 100 centers and more 50% of them are in the urban centers only.

If we were to look at a five- year horizon for Telemedicine in India, efforts would be considered successful only if we have Telemedicine reaching out to at least all district and Taluk level hospitals throughout the country. But for this to be a reality, we need a major thrust not from the Government and Private Sector but also help from International agencies, which will go a long way in achieving this objective.

One of the key factors to success of Telemedicine in India is going to be the reliability of telecommunication link. In this context, it is of considerable significance the commitment made by ISRO Chairman to provide free bandwidth for the purpose of Telemedicine and Tele-education. ISRO has been deploying satellite based telemedicine nodes in collaboration with state governments. So far it has deployed around 250 nodes across the country.

Ministry of Health and Family Welfare has set up a National Task Force to address various issues to promote telemedicine in the country and has launched a major country wide network of district hospitals and medical colleges under the Integrated Disease Surveillance Project. National Cancer Care Network and Medical Colleges network are going to be implemented in the near future.

In view of a number of laudable but disparate efforts and initiatives, need for an over arching architecture/ framework for the country covering 3 levels, namely, PHC to District, District to referral/ Super-specialty hospitals and also covering hardware/software requirements, bandwidth and connectivity issues has been felt. This paves the way for introduction of integrated telemedicine network in India.

Fiber optic network across the country has been laid down by both government / public sector and private telecommunication service providers paving the way for availability of high bandwidth terrestrial connectivity to build ubiquitous health network for telemedicine country wide with competing price. What started as application of science and technology in the field of telemedicine by the Ministry, it has now got a significant attention as an important national programme5. Scope of the Project Design, development and implementation of low cost rural telemedicine infrastructure consisting of fixed, mobile and hand-held platforms and web technology based broad band wired / wireless wide area network centering around the district hospital acting as hub.

Design and development of Village Tele-ambulance System and rural emergency healthcare services / Trauma care module, a new concept, through mobile telemedicine network based on Wi-MAX wireless mesh network Development of Rural Health Knowledge Resource through web portal on public health domain and creation of e-CME module for its access by the stake holders through e-learning technology on the telemedicine platform Development of technology platform for harvest, compilation, storage (Data Base) at regional district hub and central Data Center at MOH & FW, archive and distribution across network.6. Expected Benefits

Timely access to diagnostic, specialty healthcare advice at the grass root level through the low cost telemedicine network centering around the district hospital as the service provider Augmented rural healthcare delivery system by integration of low cost, sustainable, scalable fixed, mobile and hand-held telemedicine technology platform into existing rural healthcare services infrastructure

Creation of a model for Rural Emergency / Trauma services on Telemedicine infrastructure

Improvement on knowledge base of the rural population (to empower the rural folks on self healthcare disease prevention & health promotion)

Remote education, training / retraining and skill development of grass root healthcare workers and professionals under NRHM

Ensuring public health related data (as has been incorporated under NRHM) harvest , compilation, storage at district hub, archive and distribution across network to facilitate electronic governance of NRHM.7. Proposed Guidelines / Framework for Indian Rural Telemedicine Network7.1. Defining a National Rural Telemedicine Network

While ISRO is providing free bandwidth through V SAT connectivity, we are also looking forward to defining a modal for a National Telemedicine connectivity GRID on hybrid model utilizing existing terrestrial fiber optic and upcoming wireless media technology. This would look at utilizing bandwidth across different communication links depending on the application and the investment considerations. The specific structure of any particular telemedicine center of the network would depend on the geographic factors of the area that will be serviced by the network, and the type of local users there. We visualize the National Rural Telemedicine Network to be a tiered hierarchical structure. This would include:

LEVEL-1: Primary Health Center (PHC) / Community Health Center (CHC) connected to a District Hospital LEVEL-2: District Hospital connected to a State Hospital / National Super Specialty Hospital LEVEL-3: State Hospital / National Super Specialty Hospital connected to each other LEVEL-M: Mobile Telemedicine Unit covering few villages connected to nearest PHC / CHC or directly to District HospitalWith special reference to NRHM the PHCs can be scaled down to village level units up to Village health worker in the proposed networkThe LEVEL-1 units are referring in nature and will connect to a pre-designated LEVEL-2 unit that is referral in nature. It is possible that LEVEL-2 unit may also act as a referring unit and refer to LEVEL-3 unit. In such a case, LEVEL-2 unit will also require some medical equipment. LEVEL-3 units are purely referral in nature and will be able to consult with each other or refer a case to each other on basis of specialty and requirement of second / third / nth opinion.In defining the National Rural Telemedicine Network, selecting the connectivity will be defining factor in reaching out to distant locations including where traditional land based communication systems have not yet reached or are plagued by poor connectivity.

This network needs to be based on open platform and on open architecture standards that make it accessible to one and all. It would not be restrictive in any way and any party interested to contribute to or benefit from this noble application would be able to do so. Developing an adequate and affordable telemedicine infrastructure can help to close the gap between the haves and the have-nots in health care.

7.2. Standardization First Step Towards National Rural Telemedicine NetworkAs a starting point of building the National Rural Telemedicine Network, MoH&FW has initiated defining the national standards and guidelines for Telemedicine application in India, in consultation with DIT, MCIT. Telemedicine working group setup has already finalized a nucleus framework Recommendation on Guidelines, Standards and Practices for Telemedicine in India. Defining standards now will insure that all our systems are interoperable and are able to communicate with each other instead of being restrictive and limited to a particular provider network. What this means is that if a center has a Telemedicine system already implemented, it can talk to another center with different Telemedicine System as long as they adhere to the defined standards. This will also form the basis of collaborations - between the government and private players as well as between different private players with the patients being the final beneficiaries.

7.3. Constituents of Telemedicine NetworkA telemedicine network incorporates following components in addition to Consulting Doctors and Super Specialty Consultants at both recipient and referral hospitals:

7.3.1. LEVEL-1: Primary Health Center (PHC) / Community Health Center (CHC) / Village Unit Tele-consultation room Patient engagement facilities (bed, scopes, etc.)

Telemedicine Platform

Selective medical and medico-IT equipments, preferably IT compatible, with interface to Telemedicine and/or other software / hardware Computer hardware / software platform (PC, switch, etc.) and IT electronics equipments Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) Point-to-Point video-conferencing system (may be portable)

7.3.2. LEVEL-2: District Hospital Telemedicine room Patient engagement facilities (bed, scopes, etc.) Telemedicine Platform

Selective medical and medico-IT equipments, preferably IT compatible, with interface to Telemedicine and/or other IT software / hardware

Computer hardware / software platform (PC, server, switch, etc.) and IT electronics equipments Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broad band, Wireless)

Multi-point video conferencing system Optional telemedicine software access facility at consultants room through Hospital-LAN

Optional secure centralized long-term electronic record storage for assigned LEVEL-1 and LEVEL-M units

Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) Note that:

District Hospital may act as referring/consulting unit as well and may have some medical equipments for tele-consultation with State Hospital / National Super Specialty Hospital

All units will require multiple telemedicine stations for simultaneous tele-consultation with referring units7.3.3. LEVEL-3: State Hospital / National Super Specialty Hospital Telemedicine room

Telemedicine Platform

Computer hardware / software platform (PC, server, switch, etc.) and IT electronics equipments

Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broad band, Wireless)

Multi-point video conferencing system

Optional telemedicine software access facility at consultants room through Hospital-LAN

Optional secure centralized long-term electronic record storage for assigned LEVEL-1, LEVEL-2, and LEVEL-M units

Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless)

Note that:

All units will require multiple telemedicine stations for simultaneous tele-consultation with referring units

7.3.4. LEVEL-M: Mobile Telemedicine Unit * Automobile Vehicle Chasis Size: 5.779 X 2.188 X 1.900 mts Customized fabrication to accommodate IT and medical equipments Integrated DG set Space for tele-consultation, patient examination

Space for carrying out investigation procedures like Ultra-sonography and X-ray Telemedicine Platform

Selective medical and medico-IT equipments, preferably IT compatible, with interface to Telemedicine and/or other IT software / hardware

Computer hardware / software platform (PC, server, switch, etc.) and IT electronics equipments

Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) Point-to-Point video-conferencing system (may be portable) Besides vans, Mobile Telemedicine units can be customized for deployment in any of the following:

Boat (e.g. for application on back water regions in Kerala or in Brahmaputra in Assam)

Chhakras (e.g. used in Gujarat)

Camel Carts (e.g. in deserts of Rajasthan) Application specific mobile units can be configured:

Tele-ophthalmology

Tele-Cancer care

Tele-Ambulance for Trauma Network and Rural Emergency system

Suitcase-based Telemedicine module for Disaster-hit area, etc. Mobile hand held units to act as data harvesting point for NRHM at the grass-root level

* Each state will have initially 02-04 units depending on the size and population. Alternatively, the mobile vans procured under NRHM may be made telemedicine-enabled with suitable modifications and installations. 7.3.5. NRHM Smart CardAt low investment, we can have the rural citizen health record incorporating life time health events starting from cradle to grave. Hence, this device integration under Rural Telemedicine network may be considered.7.4. Process and Infrastructure Guidelines at Different Layers of Hierarchy

7.4.1. Telemedicine Process for LEVEL-M and LEVEL-1 unitsThe proposed Mobile Telemedicine Unit, Primary Health Center (PHC) / Taluk Hospital are rural based health center catering to rural population. The Mobile Telemedicine Unit is understandably mobile version of similar setup at PHC / CHC.

Through LEVEL-M and LEVEL-1 telemedicine consultation center, patients data and reports can be sent to District Hospital and get the second / expert opinion. Typically, these centers do not have very good diagnostic facilities, hence, some basic equipment outlined below needs to be installed wherever not present.

Communication link between LEVEL-1 and District Hospital (LEVEL-2) could be through Wi-MAX, Broadband, or V-SAT connectivity depending on availability. A sustained bandwidth of 512 kbps or more for videoconference and data transmission is deemed sufficient.Basic setup will have a single multimedia computer system and IP-based Video conference system with PTZ facility. Diagnostic reports of the patient are forwarded to District Hospital using the telemedicine software system. Film Scanner may be used for sending X-ray / CT / MRI images and Tele-microscopy system to send smear for parasite in blood and urine for bacteriological studies. Additionally, a digital ECG device may also be provided. A basic printer may also be provided for printing report and records for distribution to patient.The telemedicine functionality at these units may be either:

A self-sufficient system with ability to create and maintain long-term electronic medical record (EMR) of patient, view, connect, transmit, and retrieve expert opinion. This model supports offline, online, and interactive telemedicine creating complete technological base of all types of services / modalities. A web-based / thin-client access to Servers at LEVEL-2. This model supports offline, and web-based telemedicine creating sufficient and cost-effective technological base of all types of services / modalities. However, in this model, the unit should be able to locally create new record of new patient (some type of reduced function but still usable) in case of disconnection with LEVEL-2 servers. The locally created records should be uploaded to LEVEL-2 server when connectivity is restored.

7.4.2. Telemedicine Process for LEVEL-2 and LEVEL-3 unitsThe proposed setup at District Hospital (LEVEL-2) has dual purpose. It acts as a referral unit for all LEVEL-1 and LEVEL-M units assigned to it. It also acts as a data collection and referring unit for LEVEL-3 units. Film Scanner may be used for sending X-ray / CT / MRI images and Tele-microscopy system to send smear for parasite in blood and urine for bacteriological studies. Additionally, a digital ECG device may also be provided. A mid-size printer may also be provided for printing report and records for distribution to patient and provide hard-copy reports to experts / specialist for discussion / deliberation.

The LEVEL-3 units are purely referral in nature and provide expert opinion on data sent from District Hospitals or those generated at PHC level and then forwarded by District Hospitals assigned to it.

Due to nature of these units being referral in nature, with multiple lower level units connecting, transmitting data, and requiring expert opinion / intervention, it is necessary to provide multiple telemedicine stations at these locations. These units will have multi-point video-conferencing system so that it can cater to various locations at a time.

Communication link between LEVEL-2 and LEVEL-3 units can be over terrestrial fiber optic cables, Wi-MAX, Broadband, ISDN, or V-SAT connectivity depending on availability. A sustained bandwidth of 512 kbps or more for videoconference and 256 kbps per simultaneous data transmission is deemed sufficient.

Setup at each such location will consist of a Server (or a Server farm in case of large load) with multiple client / access units for telemedicine. Fail-safe long-term data storage servers to store data generated at local location and lower-levels need to be established. To promote anytime/anywhere telemedicine access, all consultants in the program should be provided with access support at their room in hospital through hospital LAN. Additionally, some active consultants may be provided dial-up or Wi-Fi access from a laptop depending on nearness to the facility.The telemedicine functionality at these units may be either:

A Server / Client system with ability to create and maintain long-term electronic medical record (EMR) of patient, view, connect, receive/transmit, and retrieve/send expert opinion. This model supports offline, online, and interactive telemedicine creating complete technological base of all types of services / modalities. A web-based access system for consultant from their room or via laptop/home may also be provided.

A web-based Server system having all facility to allow local consultant and remote LEVEL-1 and LEVEL-M doctors to connect, create, store, retrieve EMR and provide/retrieve expert opinion. This model supports offline, and web-based telemedicine creating sufficient and cost-effective technological base of all types of services / modalities.

7.4.3. Telemedicine Hardware / Software Requirement at LEVEL-M and LEVEL-1S.N.ItemQty

1.Desktop PC platform Intel Core2 2.4GHz (or equivalent), 1024MB RAM, 400GB SATA2 HDD, DVD-RW Drive, 10/100/1000 NIC Appropriate 3rd party Software (AV, personal database)

Windows XP Professional, MS Office Standard

Hardware Accelerator Graphics Card (dedicated 256MB onboard RAM)

Keyboard and mouse (Optionally Wireless) 19 TFT LCD monitor

Suitable Web-Camera for interaction during Online Tele-Consultation Microphone, Stereo Speakers and Headset01

2. Peripherals Laser Printer, 4-port USB Hub, etc. Network device 8 port 10/100/1000 Mbps switch and patch cables 1 KVA Line-interactive UPS01

3.IP Video Conferencing Kit 128 Kbps IP based VC unit 29 LCD TV (with wall mounting kit)01

4.Telemedicine software (either of following)

Interactive Self-sufficient (with remote interactive connect to LEVEL-2 units) Local Web-based reduced-functionality module (with connectivity to remote Web-based Server)01

5. Digital ECG A3 Film Scanner

Digital Microscope

Digital Camera

Glucometer

Non-invasive Pulse & Blood Pressure unit Additionally Mobile Van will have Ophthalmoscope Mobile USG Portable X-ray Unit with CR Haematogram Analyser01

6.Connectivity device (either of them) ISDN Modem (with NT)

ADSL2+ / CDMA / PSTN Modem

VSAT SkyIP unit

Wi-MAX CPE Fiber Optic CPE01

7.Optionally 2/4 module router with items in S.N. 6(in case of multiple connectivity medium)

In case of ISDN lines, dial-up router must be taken01

7.4.4. Telemedicine Hardware / Software Requirement at LEVEL-2S.N.ItemQty

1.Telemedicine Server Platform

2x Dual Core Intel Xeon 3.2 GHz (or equivalent), 4096MB RAM, DVD-RW Drive, Dual 10/100/1000 NIC, Remote management Appropriate 3rd party Software (AV)

Operating System (depending on telemedicine solution chosen):

Windows 2003 R2 Standard Server, MS Office Standard, MS SQL Server RedHat Enterprise Linux 5 Standard, PostgreSQL Integrated Graphics Card

Wireless Keyboard and mouse

19 TFT LCD monitor

Onboard RAID Controller and Hot-swap disks 2x 36 GB SCSI / SAS RAID-1 for OS 4x 300 GB SCSI / SAS RAID-601

2.Optional Telemedicine Central Data Storage Server(may be combined with S.N. 1 with spec increase)

Dual Core Intel Xeon 3.2 GHz (or equivalent), 2096MB RAM, DVD-RW Drive, Dual 10/100/1000 NIC, Remote management Appropriate 3rd party Software (AV, Database)


Windows 2003 R2 Standard Server

RedHat Enterprise Linux 5 Standard Integrated Graphics Card


19 TFT LCD monitor

Onboard RAID Controller and Hot-swap disks (may be on separate enclosure) 2x 80 GB SATA2 RAID-1 for OS 12x 500 GB SATA2 RAID-601

3.Optional Tape Library and Backup system

Ultrium 3 Technology 6 TB Native Backup capacity SCSI Interface Backup software with appropriate agents01

4.Desktop PC platform

Intel Core2 2.4GHz (or equivalent), 1024MB RAM, 400GB HDD, DVD-ROM Drive, 10/100 NIC

Appropriate 3rd party Software (AV, Database)




19 TFT LCD monitor

Suitable Web-Camera for interaction during Online Tele-Consultation

Microphone, Stereo Speakers and Headset03

5. Peripherals Laser Printer, 4-port USB Hub, etc.

Network device 8 port 10/100 Mbps switch and patch cables 4 KVA On-Line UPS01

6.IP Video Conferencing Kit

512 Kbps IP based VC unit 32 LCD TV (with wall mounting kit)01

7.Telemedicine Client software (either of following)

Interactive Telemedicine Client (with interactive connect to Telemedicine Server) Local Web-based access (with connectivity to Web-based Server)01

8.Telemedicine Server software (either of following)

Interactive Telemedicine Serve with Web access module Web-based Telemedicine Serve

9. Digital ECG

A3 Film Scanner

Digital Microscope

Digital Camera

Glucometer

Non-invasive Pulse & Blood Pressure unit01

10.Connectivity device (either of them)

ISDN Modem (with NT)


VSAT SkyIP unit


11.Optionally 2/4 module router with items in S.N. 6

(in case of multiple connectivity medium)


7.4.5. Telemedicine Hardware / Software Requirement at LEVEL-3S.N.ItemQty

1.Telemedicine Server Platform

2x Dual Core Intel Xeon 3.2 GHz (or equivalent), 4096MB RAM, DVD-RW Drive, Dual 10/100/1000 NIC, Remote management Appropriate 3rd party Software (AV)


Windows 2003 R2 Standard Server, MS Office Standard, MS SQL Server

RedHat Enterprise Linux 5 Standard, PostgreSQL Integrated Graphics Card


19 TFT LCD monitor

Onboard RAID Controller and Hot-swap disks

2x 36 GB SCSI / SAS RAID-1 for OS 4x 300 GB SCSI / SAS RAID-601

2.Desktop PC platform

Intel Core2 2.4GHz (or equivalent), 1024MB RAM, 400GB HDD, DVD-ROM Drive, 10/100 NIC

Appropriate 3rd party Software (AV, Database)




19 TFT LCD monitor

Suitable Web-Camera for interaction during Online Tele-Consultation

Microphone, Stereo Speakers and Headset03

3. Peripherals Laser Printer, 4-port USB Hub, etc.

Network device 8 port 10/100 Mbps switch and patch cables 2 KVA On-Line UPS01

4.IP Video Conferencing Kit

512 Kbps IP based VC unit 32 LCD TV (with wall mounting kit)01

5.Telemedicine Client software (either of following)

Interactive Telemedicine Client (with interactive connect to Telemedicine Server) Local Web-based access (with connectivity to Web-based Server)01

6.Telemedicine Server software (either of following)

Interactive Telemedicine Serve with Web access module Web-based Telemedicine Serve

7.Connectivity device (either of them)

ISDN Modem (with NT)


VSAT SkyIP unit


8.Optionally 2/4 module router with items in S.N. 6

(in case of multiple connectivity medium)


7.5. Proposed Organizational Plan7.5.1. Preparation of Infrastructure, E-Health Education and Training

Adequate physical infrastructure is now made available in many of the rural PHCs / CHCs and District hospitals with World Bank aid under Health System Development project. Even many district hospitals have now advanced medical equipments including CT scan, Coloured Doppler etc. Under NRHM health worker and professional capacity is building up. However, Ministry of Health & Family Welfare has to play the key role in ensuring e-readiness both in terms of physical infrastructure and e health education & training at all levels of hospitals before starting clinical telemedicine process.The bandwidth and communication infrastructure is crucial for the success of the program. Communication agencies that have nationwide footprint (e.g. BSNL) need to be roped in for providing connectivity at all location with internal virtual routes between all units. In such a scenario, only last mile connectivity is to be provided while a nationwide network is already in place.

Simultaneously, some Medical training institute should also be made part of the program to promote CME and self-paced training program for Anganwadi / local health workers and doctors at LEVEL-M, LEVEL-1, and LEVEL-2. The training can be delivered over the same network.

7.5.2. Setting Guidelines for Administration and Clinical, Educational and Governance Telemedicine PracticesThe MoH&FW should appoint a National Director (with adequate seniority level) for the program advised / assisted by a nuclear expert panel of people / organizational representatives experienced in Telemedicine program planning and role-out. Similarly, a State Director (with adequate seniority level) reporting to the National Director should be appointed to ensure smooth role-out and functioning of the program. A District Director at LEVEL-1 and LEVEL-M shall ensure programs success. The nucleus framework Recommendation on Guidelines, Standards and Practices for Telemedicine in India. Specifies various guidelines that need to be followed by all units for proper functioning.

7.5.3. Identification of Vendor for Project ImplementationThere are various Telemedicine technology providers in the country. DIT, MCIT has funded some very successful Telemedicine programs in the nation and may be consulted on selecting a suitable Telemedicine technology platform for adaptation in the program. It is important that chosen technology is supported and sustained, preferably by a national technology agency, for the period of program and beyond it.

Once the Telemedicine technology platform is identified, then selection of other hardware and software should be done in close consultation with chosen technology provider. However, a mechanism of open tender should be encouraged in purchase of identified hardware and software.The implementing agency need to have national reach and experience in executing Telemedicine project.

7.5.4. Recruitment of Technical / Medical Manpower

The manpower employed for the program are very crucial to the success of program. In case manpower is drawn from existing strength / positions, a mechanism of incentives need to be put in place that will encourage staff to engage fruitfully. All appointments can be on term contract basis with periodic performance review.7.5.5. Installation of Equipments, Network Media, Testing, Training and Hand-HoldingSite identification, preparation, and installation will be taken in phased manner. The implementer shall provide for at least 6 months of hand-holding to the deployed location. Hand-holding can be done remotely. A training, as appropriate according to function / role, need to be provided to staff on the program by implementing agency.7.5.6. Periodic Monitoring and Preparation of Interim Report

The program directors will be responsible for monitoring the program throughout its implementation and use period.7.5.7. Impact Evaluation at the End of Each Year and After Five Year

A suitable mechanism to review effectiveness of program at end of each year and a broad review at the end of 5 year period need to be done by program directors and report be prepared for placing before MoH&FW.

8. Budget requirementThe project needs to be implemented in phases.8.1. Financial Requirement for Phase-I

During the first phase of the project, it is proposed to link up following in Phase-I:

100 LEVEL-1 (PHC / CHC / Village) units

50 LEVEL-2 (District Hospitals) units 5 LEVEL-3 (State Hospitals / Super Specialty Hospitals) units 50 Mobile Telemedicine Van (01 per District Hospital in program)The financial requirement of Phase-I will consist of the cost for setting up Telemedicine facilities, recurring cost for operation and maintenance, and their connectivity charges.8.2. LEVEL-1 (PHC / CHC / Village) UnitsFixed CostsSl. No.Item DescriptionEstimated Value (In Rupees)Remarks

1.Recommended Medical Equipment6,00,000The list of equipment are given at Sec 7.4

2.Hardware / Software (including PC server, etc.)3,50,00

3.Telemedicine Consulting Center (TCC ) software2,00,000May vary, Interactive Self-Sufficient is assumed. Web-based module may be cheaper.

4.Video Conferencing Kit2, 50,000

5.Terrestrial IP (512 kbps) scalable10,000May vary, Broadband setup charge assumed.

6.Land, building, furniture electrical fittings, fixtures or any other non electronic item0To be provided by the hospital concerned

7.Training costs50,000To be provided by vendor, hospital bears cost of its staff.

8.Installation & Commissioning 1,00,000To be conducted by various vendors.

Total 15,60,000

Annual Recurring Costs

Sl.NoItem Description Approximate Cost (in Rupees) Remarks

1.Site Administrator + Technician3,50,000Administrator= Rs2,00,000

Technician = RS 1,50,000

2.Medical staff incentive / allowance1,08,000Doctors (01 nos) = 5000/monthMedical staff (02 nos) = 2000/month

2.Annual Maintenance Charges Hardware/software per node2,00,000Assuming 15% of Equipment costs + s/w subscription / update

3.Annual Update / Support Charges of Telemedicine software40,000Assuming 20% of costs

3.Annual bandwidth cost per year per node50, 000Assumed Broadband

4.Electricity, other consumables, etc 0To be provided by the hospital

Total (with incentives)7,48,000

Total (without incentives)6,40,000

8.3. LEVEL-M (Mobile Telemedicine Van)Fixed CostsSl. No.Item DescriptionEstimated Value (In Rupees)Remarks

1.Automobile Van with integrated DG set, bed and other provisions25,00,000


3.Hardware / Software (including PC server, etc.)3,50,00

4.Telemedicine Consulting Center (TCC ) software2,00,000May vary, Interactive Self-Sufficient is assumed. Web-based module may be cheaper.


6.Terrestrial IP (512 kbps) scalable10,000May vary, Broadband setup charge assumed.

7.Van Equipment integration1,00,000

8.Training costs50,000To be provided by vendor, hospital bears cost of its staff.


Total 71,60,000

Annual Recurring Costs

Sl.NoItem Description Approximate Cost (in Rupees) Remarks

1.Site Administrator + Technician + Van operator4,46,000Administrator= 2,00,000


Operator=96,000

2.Medical staff incentive / allowance1,56,000Doctors (01 nos) = 8000/month

Medical staff (02 nos) = 2500/month


3.Annual Update / Support Charges of Telemedicine software40,000Assuming 20% of costs

3.Annual bandwidth cost per year per node50, 000Assumed Broadband

4.Fuel, Van maintenance 0To be provided by the hospital



8.4. LEVEL-2 (District Hospitals)Fixed Cost

Sl. No.Item DescriptionEstimated Value (In Rupees)Remarks


2.Hardware / Software (including PC, servers, etc.)11,50,00

3.Optional Storage Server + Backup8,00,000

4.Telemedicine Consulting Center (TCC ) software7,50,000May vary, Interactive Client is assumed. Web-based module may be cheaper.

5.Telemedicine Server Software5,00,000


5.Terrestrial IP (2 mbps) scalable10,000May vary, Broadband setup charge assumed.


7.Training costs1,00,000To be provided by vendor, hospital bears cost of its staff.


Total (with optional items)49,60,000

Total (without optional item)41,60,000

Annual Recurring CostsSl.NoItem Description Approximate Cost (in Rupees) Remarks






3.Annual Update / Support Charges of Telemedicine software2,50,000Assuming 20% of costs

3.Annual bandwidth cost per year per node1,50, 000Assumed Broadband




8.5. LEVEL-3 (State Hospital /Super Specialist Hospitals)Fixed Cost

Sl. No.Item DescriptionEstimated Value (In Rupees)Remarks

1.Recommended Medical Equipment0No medical equipment

2.Hardware / Software (including PC, servers, etc.)11,00,00

3.Telemedicine Consulting Center (TCC ) software7,50,000May vary, Interactive Client is assumed. Web-based module may be cheaper.

4.Telemedicine Server Software5,00,000


6.Terrestrial IP (2 mbps) scalable10,000May vary, Broadband setup charge assumed.


8.Training costs1,00,000To be provided by vendor, hospital bears cost of its staff.


Total 35,10,000

Annual Recurring CostsSl.NoItem Description Approximate Cost (in Rupees) Remarks






3.Annual Update / Support Charges of Telemedicine software2,50,000Assuming 20% of costs

3.Annual bandwidth cost per year per node1,50, 000Assumed Broadband




8.6. Financial Summary

Although there are various varying components in the tentative budget provisions given above, here the maximum value per unit is taken to know the extent of budget. Communication setup and running cost may change completely depending on the type of connectivity chosen finally.

UnitFixedRecurringQtyTotal

LEVEL-M71,60,00013,22,0005042,41,00,000

LEVEL-115,60,0007,48,00010009,04,00,000

LEVEL-249,60,00014,14,5005031,87,25,000

LEVEL-335,10,00011,97,000502,35,35,000

Total20585,67,60,000

The total budget (using maximum component valve, except connectivity) come to around Rupees Eight-Five Crore Sixty-Seven Lakhs Sixty Thousand only.PAGE 23

national rural telemedicine network for india- mohfw

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