Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred through the phone or the Internet and sometimes other networks for the purpose of consulting, and sometimes remote medical procedures or examinations. Care at a distance (also called in absentia care), is an old practice which was often conducted via post. There has been a long and successful history of in absentia health care which, thanks to modern communication technology, has evolved into what we know as modern telemedicine.

In its early manifestations, African villagers used smoke signals to warn people to stay away from the village in case of serious disease. In the early 1900s, people living in remote areas in Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service of Australia

DEFINITION

Telemedicine has been defined as the use of telecommunications to provide medical information and services (Perednia and Allen 1995). 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 or robotic technology. The first is used daily by most health professionals, and the latter is used by the military .

The use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care. Telemedicine includes consultative, diagnostic, and treatment services.

Telemedicine or Telehealth?

The term 'telehealth' was originally used to describe administrative or educational functions related to telemedicine. Now that physicians use email to communicate with patients, and drug prescriptions and other health services are being offered on the Web, 'telehealth' is generally used as an umbrella term to describe all the possible variations of healthcare services using telecommunications. The term 'telemedicine' more appropriately describes the direct provision of clinical care via telecommunications--diagnosing, treating or following up with a patient at a distance. However, stay tuned. The terminology used to describe healthcare services at a distance will likely change as fast as the technology used to perform it.

Applications of telemedicine

The primary applications of telemedicine are clinical,educational,administrstive and research. 1- Clinical applications include initial patient evaluations, diagnosis(telediagnosis) and teleconsultation.physician supervision of non physicians and monitoring of patient status are possible.

- Continuing education for professionals is available as is patient nd community education.(tele-education)administrative uses such as conferences,scheduling and utilization and quality review may be provided.

- Research is enhanced by aggregation of data from multiple sources and coordination.

Telemedicine allows access to the wealth of information available on the internet. this allows information to be at the touch of a finger.the availability of e-mail allows an efficient

mechanism of communication between consulting and primary physicians. Communication between facilities is enhanced.

Objectives of telemedicine

“TeleMedicine is not an evolutionary concept but a revolutionary concept and at the heart of every revolution, there is the need for a sudden massive change, at the core of which is the human mind.”

By taking into consideration “Health For All,” we’ll discuss some objectives for which TeleMedicine has originated.

1. To make high quality healthcare available to traditionally under privileged population - In India, there is a large rural based population separated by large distances which need access to regular quality medical care. Telemedicine can enhance citizen’s equality in the availability of various medical services and clinical health care, despite these economic and geographic barriers.

2. Save the time wasted by both providers and patients in traveling from one geographic

location to another to avail services on time- Think of a patient who requires immediate specialist consultancy, and there is no specialist available to cater to him. This is where e-medicine could be utilized for effective healthcare delivery.

3. Reduce costs of medical care – The ever- rising cost of healthcare is becoming a prime concern. 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 overall cost of treatment. In a country where health insurance is yet to catch up, all these are 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. E-medicine seems to be the answer

Types of telemedicine

Telemedicine can be broken into three main categories: store-and-forward, remote monitoring and interactive services.

Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of this transfer. A key difference between traditional in-person patient meetings and telemedicine encounters is the omission of an actual physical examination and history. The store-and-forward process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination.

Remote monitoring, also known as self-monitoring/testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective.

Interactive telemedicine services provide real-time interactions between patient and provider, to include phone conversations, online communication and home visits. Many activities such as history review, physical examination, psychiatric evaluations and ophthalmology assessments can be conducted comparably to those done in traditional

face-to-face visits. In addition, “clinician-interactive” telemedicine services may be less costly than in-person clinical visits.

EQUIPMENTS OF TELEMEDICINE:-

Transmission equipment varies according to the transmission mode,analog or digital and the

means of transporting the mode,satellite or terresterial. There are two transmission modes:-

- the first is analog,which is the transmitting of waves, similar to television broadcasts.

Its advantages include high resolution and familiarity.

The high expanse associated with transmission, large size and complexities of required hardware

are disadvantages.

The digital mode utilizes the transmission in the form of “bits”.transmission costs,smaller

equipment,simplicity of operation,ease of interface(including the storage and revival systems for

image and data)are several benefits of this mode.it is preferred due to cost,usability and

expansion potential.

The transmission mode may be transported via satellite or terresterial media.terresterial

modes include microwave,fiber-optic and conditioned copper cables.satellite transmission allows

a full motion broadcast quality picture.most satellites transmit analog signals.signals may be

transported on C-Band KU-Band.the C-Band is often utilized by local telephone

companies,requiring coordination of availability.The KU-Band utilized by television stations is

more widely available.

Satellite transmissions have no boundary restrictions.it allows transmission of large

amount of information.it is ideal for sending visual information to multiple locations.

The disadvantage is the cost.it is approximately eight times as expensive as terresterial

transmission.the cost may be as high as $450 per hour for prime time use to $250 per hour for

non prime time.

Terresterial transmission is less expensive to operate on an hourly basis but is limited to

areas that are linked to the appropriae line.videotransmission normally requires a

bandwidth(carrying capacity)of 90 million bits per second(Mbps).a telephone call requires 64

thousand bits per second.the fastet speed is available withcurrent digital technology of 1.54

Mbps.

Fiber optics is available from long distance and local telephone companies.optic fibers

consist of hair thin glass and uses light to transmit telecommunication signals.they may be lased

as a dedicated line or on demand basis.optical fiber has a wide bandwidth allowing for choices of

transmission speed.

NEED OF TELEMEDICINE:-

Improved access- over 40 years,telemedicine has been used to bring healthcare services to

patients in distant locations.not only does telemedicine improve access to patients but it also

allows physicians and health facilities to expand their reach,beyond their own offices.

Cost efficiencies- reducing or containing the cost of health care is one of most important reasons

for funding and adopting telehealth technologies.telemedicine has been shown to reduce the cost

of healthcare and increased efficiency through better management of chronic diseases,shared

health professional staffing,reduced travel times and fewer or shorter hospital stays.

Patient demand- consumers want telemedicine.the greatest impact of telemedicine is on the

patient,their family and their community.using telemedicine technologies reduces travel,time and

related stress to the patient.over the past 15 years study after study has documented patient

satisfaction and support for telemedical services.

Such services offer patients the access to providers that might not be available otherwise as well

as medical services without the need to travel ling distances.

Benefits of Telemedicine:

To Rural Physicians and clinics (spoke sites)

Receive education from the specialist/provider

Better health outcome for their patients

Enhanced community confidence in local healthcare

Attend continuing medical education courses from their clinic

To Patients

Loved ones remain in their community with family support

Cost savings from not having to travel extensively

Immediate urgent care

Confidentiality of specialty examination or visit (Because the patient visits the general

practice doctor, he can be seen for any specialty care without anyone else knowing)

Patient education courses (nutrition, oncology, etc.)

Properly stabilize patient prior to transport

Early Diagnosis prior to escalated medical episode

Rural Patient's Community

Patients that routinely travel to visit doctors in large urban areas tend to purchase their goods and

services from those cities, Telemedicine keeps those dollars local.

To Telemedicine Providers (hub sites)

Expand patient outreach

Major surgical procedures resulting from the initial telemedicine consultation

Reduction in ER visits 6

Promotion of Hospital

Charge tuition for clinician education courses (CME, CNE, etc.)

Hindrances:

• Perspective of medical practitioners : Doctors are not fully convinced and familiar with e-medicine. They cannot understand how their jobs can be performed more effectively and efficiently through the use of e-medicine. The very thought of diagnosing a patient when he/she is physically absent just on basis of the data provided through the net turns them blue. Similarly practitioners in remote areas feel threatened that they will be surpassed due the reach of brand names like APOLLO, Asia Heart Foundation etc.

• Patients’ fear and unfamiliarity : There is a lack of confidence in patients, about the outcome of E-Medicine. The main problem is that any treatment consist of two factors; first is chemotherapy i.e. treatment by medicines and the other is psychotherapy that means treatment by emotions which is absent in e-medicine.

• Financial unavailability: There has been several isolated initiatives from various organizations and hospitals for the implementation of e-medicine projects. But the technology and communication costs being too high, make it financially unfeasible.

• Lack of basic amenities: In India, nearly 40% of population lives below the poverty level. Basic amenities like transportation, electricity, telecommunication, safe drinking water, primary health services, etc. are

missing. Any technological advancement can’t change a bit when a person has nothing to change.

• Literacy rate and diversity in languages : Only 65.38 % of India’s population is literate with only 2% well-versed in English. So the rest of the people are facing a problem in adopting teleMedicine. Also, the presence of a large number of regional languages makes the applicability of a single software difficult for the entire country.

• Technical constraints : telemedicines supported by various types of software are hardware, still needs to mature. For correct diagnosis and pacing of data, we require advance biological sensors and more band-width support .

• Quality aspect : “Quality is the essence” and every one wants it, but can 7

sometimes create problems. In case of health care, there is no proper governing body to form guidelines in this respect and motivate the organizations to follow, it is solely on organizations how they take it.

• Government Support : The government has limitations and so does private enterprises. Any technology in its primary stage, needs care and support. Only the government has the resources and the power to help it survive and grow. But in India we are not the favored ones. There is no such initiatives taken by the government to develop it.

• Biological consistency : Diagnosis itself is a complex process and symptoms of disease are not consistent in all the patients. The consultant makes a disease diagnosis on the basis of information gleamed from the patient. In e-medicine the consultant tests the hypothesis, it may be right or wrong.

CURRENT STATE OF THE FIELD OF TELEMEDICINE

Telemedicine holds considerable promise for pediatrics and pediatricians. Virtually any service can be provided via telecommunications technology, but a rigorous evaluation of telemedicine's potential is hampered by a lack of high-quality studies and cost-benefit analyses, especially in pediatrics. Certain pediatric services seem well adapted to telemedicine, including the following.

Mental HealthEvidence suggests that patients are highly satisfied with psychiatric counseling delivered via telemedicine, and this is true also for children. Diagnostic accuracy seems to be excellent. Before applying telemedicine applications in mental health, it is important to consider the setting, staff capabilities, and access to information sharing.

Telecardiology

ECG or electrocardiograph can be transmitted using telephone and wireless. This was done by Barr (1958) who transmitted ECG tracings to about 40,000 feet Cardiology has already widely embraced telemedicine. Electronic stethoscopes can facilitate the transmission of heart sounds with excellent fidelity. Echocardiograms, ultrasonographic images, electrocardiograms, and other images can readily be transmitted electronically and evaluated accurately as part of established telecardiology program.

.Teletransmission of ECG using indigenous methods. One of the oldest known telecardiology system (teletransmission of ECG) was established in Gwalior, India in 1975 at GR Medical college by Dr. Ajai Shanker, Dr. S. Makhija, P.K. Mantri using indegenous technique for the first time in India.

This system enabled wireless transmission of ECG from the moving ICU van or the patients home to the central station in ICU of the department of Medicine. Transmission using wireless was done using frequency modulation which eliminated noise. Transmission was also done through telephone lines. The ECG output was connected to the telephone input using a modulator which converted ECG into high frequency sound. At the other end a demodulator reconverted the sound into ECG with a good gain accuracy. The ECG was converted to sound waves with a frequency varying from 500 Hz to 2500 Hz with 1500 Hz at baseline.

This system was also used to monitor patients with pacemakers in remote areas. The central control unit at the ICU was able to correctly interpret arrythmias. This technique helped medical aid reach in remote areas

Teleradiology

Effective teleradiology programs have been in existence for the last 30 years. Over this period, the profession has developed extensive standards for how images should be stored and displayed to ensure accurate representations. Teleradiology is the ability to send radiographic images (x-rays) from one location to another. For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving / image review station. The most typical implementation are two computers connected via Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer so that images can be printed for convenience.

The teleradiology process begins at the image sending station. The radiographic image and a modem or other connection are required for this first step. The image is scanned and then sent via the network connection to the receiving computer.

Dermatology

Many diagnostic dermatologic evaluations can be performed by using high-quality still images. Although standard video cameras used in teleconferencing systems may not provide enough detail to make a dermatologic diagnosis, special peripheral cameras termed "dermatoscopes" have proved adequate. Remote "teledermatology" consultations have become commonplace at many medical centers.

. Emergency and Transport Services

According to one study, teleconferencing provides a way by which practitioners in a remote area can receive real-time emergency consultations with acceptable diagnostic sensitivity and specificity. Emergency teleconferencing may be particularly beneficial for infants and children in rural general emergency departments, in which complex pediatric disease is seen only rarely, giving these patients the benefit of pediatric consultants where none were available previously. One of the most immediately visible cost savings of telemedicine is the decreased need to transport patients to pediatric centers for critical care.

Hospital Care and Family Communication

The Infant Carelink Program, initially developed at Beth Israel Deaconess Medical Center (Boston, MA), allows families separated from their infants to keep updated on their infants' condition and to view images of their infants while they are in the neonatal intensive care unit. Data show that parental satisfaction with care is enhanced by this system. One study showed an increase in the rate of direct discharge home from the neonatal intensive care unit, as opposed to a costly intermediate transfer to a community hospital. Media reports suggest that similar projects are in place at other hospitals. Telepathology

Similar to dermatology and radiology, this visually intensive discipline is readily amenable to telemedicine consultation, especially in developing or rural areas. Telepathology may offer some financial benefits over physical transportation of specimens, and there may be a financial model for pediatric pathology services. Patient Education and Chronic Disease

Some evidence exists that children who depend on medical equipment have access to improved care by use of telemedicine monitoring. The efficacy of telemedicine in patient education via teleconferencing to teach the proper use of asthma medications has been demonstrated, as has patient satisfaction. Similar results have been reported for childhood diabetes teaching. School Health

Some school systems are experimenting with telemedicine links to extend the range of services in school-based clinics and decrease absenteeism for illness or disease-management encounters.

Home Health

Health care professionals can remotely monitor a patient's vital signs, pulmonary function, or glucose concentration and then communicate with the patient to direct care by telephone, computer, or television monitor. Technology for this type of monitoring requires only a conventional telephone line. Communication technology has helped enable patients to remain at home while being monitored for congestive heart failure, 10diabetic control, arrhythmias, or metabolic stability. Research suggests that homebound patients are pleased with this type of home health care service. Some data suggest that telemedicine-mediated home care of children with chronic disease can save money while preserving care quality.Other ServicesAlthough not extensively studied, there also have been some promising results using telemedicine for pediatric dentistry (assessment of tooth decay), neonatal ophthalmology (retinopathy assessment), and interpretation of radiographs by neonatologists.ISSUES RELATED TO TELEMEDICINE

Subspecialty Distribution and Access Issues

The most natural use of telemedicine in pediatrics is the use of teleconferencing facilities to connect patients to pediatric subspecialists. There are a growing number of reports that suggest this is feasible and well accepted by patients.13,50–52 The ability of pediatric subspecialists to provide telemedicine care in areas now served only by adult medical specialists should increase the options and quality of services available to patients.53 Studies still need to be performed to demonstrate that subspecialty consultation by telemedicine improves access for children located in rural areas and that such programs are economically sustainable without grant support. Health care workforce studies need to be performed to evaluate assumptions about the effectiveness and penetration of telemedicine into pediatric practice.

Ethical Issues

It is possible that telemedicine could create a 2-tiered system in which patients who are able to pay are granted in-person access and poor children are treated by telemedicine. On the other hand, will off-hours telemedicine consultation become available only to those who can pay while poorer patients wait for an in-person encounter?

Educational Issues

There are several educational considerations related to teaching telemedicine as a technique in pediatric residency. For example, should proficiency with telemedicine equipment be assessed to determine an understanding of telemedicine applications and technologies? An assessment could be done at telecommunications facilities used in telemedicine to provide supervision for residents and students in, for example, rural or other underserved communities. Special educational training programs for pediatric subspecialists would provide the preparation needed to assist patients via telemedicine. Residency training programs that incorporate a multidisciplinary approach may provide an additional benefit. A multidisciplinary telemedical program might include primary care pediatricians, pediatric medical subspecialists, pediatric surgical specialists, primary care physicians, and other midlevel practitioners. As the need for telemedicine increases, medical schools and residency training must prepare to train physicians using the latest techniques in the 21st century.

REIMBURSEMENT ISSUES

Physicians have been relatively slow to adopt telemedicine. Where telemedicine has been used, it has frequently been a demonstration or research project and has been supported by grants and contracts. Without the widespread agreement by insurers on reimbursement issues surrounding telemedicine, the adoption of this technology may be delayed. There is little solid research examining how reimbursement for physician telemedicine services has developed in real-world settings. There is no literature on the need for parity with other specialties of pediatric reimbursement for telemedicine care. Such evaluations need to be performed before a long-term commitment by the pediatric community is likely to occur.

 

TELEMEDICINE IN INDIA

Agencies like ISRO,Dept. of IT, Railways, few state governments, private network by Apollo,AIMS,ESCORTS etc and are also part of this movement in their own capacity.

Efforts by ISRO:

Space based Rural development Programmes since 1990s. Major thrust for TM as a special programme since 2001 Spearheading the Telemedicine Movement in India with the largest network and continuous improvement.

ISRO’s Initiative in Telemedicine

- ISRO initiated Telemedicine programme in 2001 as a special programme for

- providing Telehealth to the un served and the under-served.

- Set up Telemedicine facilities in distant and rural of India to supplement the general healthcare infrastructure.

Advantages of Satellite Communication

1. Easy reach,quick installation2. No geographical and environmental barriers

3. Flexible, high quality network

4. extensive and consistent geographic image

5. efficient support to broadcast and multipoint communications for medical education and consultation sessions

6. network capacity flexibility,reliability and security

ISRO’s Telemedicine program

- Thrust areas

Growth of TM Applications

2001: Tele-radiology- still images

2002: Tele-cardiology- moving images

2003: Tele-pathology,Tele-ophthalmology

2004: Tele-oncology, Tele-surgery

2005:Mobile Telehealth- augmentation

2006: Telemedicine from primary health care

…………the journey continues

Approach followed by ISRO

1. Proof of concept- Technology demonstration through Pilot Projects in several states2. Development of national standards and guidelines

3. Efforts to optimize the clinical requirements for evolving a suitable e-health technology

4. Efforts to minimize the costs to bring in affordability and maximize the reach

5. Encouraging new models and efforts like innovative insurance schemes

6. Integrating the health care administrators,planners, technologists and entrepreneurs and bringing all the stake holders to a common platform

7. Training and educating users (doctors and patients) to create interest in utilizing telemedicine and e-health tools

8. Developing Mobile healthcare system for reaching the doorsteps of the rural population.Telemedicine Standards in INDIA

Guidelines and standards for-

Telemedicine system

Network / Connectivity

Interoperation of Telemedicine Systems

Standards for security and process guidelines

Efforts to standardize healthcare data interchange using

DICOM-Digital Imaging and Communication in MEDICINE

H L 7 –Health Level Seven

ITU standards for videoconferencing

ISRO Telemedicine programme

. All states represented including the far flung areas like –J&k;Andeman and Nikobar Islands,Lakshadweep,Uttaranchal and North East etc.

. Special networks for army,navy and air force

.Nodes

. 181 remote hospitals

. 40 speciality hospitals

National Task Force Constituted by Federal Ministry of Health and Family Welfare

- To make TM to enter the mainstream of Healthcare delivery

- To define a national TM grid and consider its standards and operational aspects

- To identify and evaluate all players and projects currently involved in TM in India

- To prepare National Cancer TM Network

- TO define standards and structures of patient data base 19

- To draft a National Policy on TM to prepare a central scheme for the 11th FYP.

Awareness programme & International Cooperation

. In Telemedicine India 2005- attended by various international specialists

. Joint working group with Canadian Space Agency

. ISRO CNES interaction on technology

. Asia Pacific Telemedicine collaboration under ITU

. Interaction with WHO, ISFT and other agencies

. UN OOSA Workshop in China,India

. Training programme for Afghanistan

. UN workshop in India

JOURNAL REFERENCE

5th National and International Congress Telemedicine Societyf India.

Submitted by Reach Out PR on November 5, 2009 - 10:56

-Doctors, Medical practitioners, Pharma industry , IT Healthcare ,Service providers ,CEO's Administrators of Hospitals ,Telemedicine solution providers from across the country and abroad will attend the conference.

-To be held on 6th, 7th and 8th November 2009 at Le Meridian, Pune.

Pune, 30 th October 2009 : The Telemedicine Society of India in association with International society for Telemedicine and eHealth along with Grant Medical Foundations Ruby Hall Clinic, will organize the 5th National and International Conference “TELEMEDICON 2009” from 6th to 8th November 2009 at Hotel Le Meridien Pune. 20

Giving information about the conference Dr. B. S. Ratta, Organizing Chairperson- Telemedicon 2009 said, “It gives me immense pleasure to be a part of the Telemedicine conference. This conference will be attended by over 300 delegates from all over the country and abroad. Telehealth will impact all the facets of healthcare industry, and will be an integral part of the healthcare infrastructure to take healthcare to the masses. Telemedicine can bridge the rural urban divide empowering patients and the local doctors in the villages." This enables healthcare delivery locally.

The conference will be attended by many dignitaries and officials from the Ministry of Health, Ministry of Communication and IT, Department of Science and Technology. Officials from ISRO and CDAC, and CEOs and Deans of Hospitals are among others who will be attending the conference.

The theme of the conference will be “i- Health” (i.e. Individual’s Health) Redefining Telemedicine. Telemedicon 2009 will provide with a matchless opportunity to update on the developments in Telehealth, interact with the who’s who in Telehealth. This conference will be solicited not only by the medical specialists but also by business houses, IT companies, Insurance sector, Tele communication companies, pharma industries, clinical trials, equipment manufacturers, government and non government organizations, administrators and researchers in the field of medicine. It will be a gateway for new opportunities for knowledge sharing finding potential prospects for a business association.

Telemedicine Society of India works to promote and encourage development, advancement in the science of telemedicine and its associated fields. They also strive to encourage and promote the application of telemedicine technology in clinical care, education and research in the health sector. Ideas and solutions in Telemedicine will be showcased along with workshop Do It Yourself Telemedicine.

BIBLIOGRAPHY

1. Buchsel patricia;Mia skowski Christine; Oncology Nsg; Assessment Clinical care;Mosby Publications;1st edition; Ch- 17; Pp-347.

2. Rostant Miller Donna; Caddy F. Rebecca; AWOHN; Association of Women’s Health Obstetric and Neonatal Nursing; Liability Issues in Perinatal Nursing; 2nd Edition; Lippincott Publishers; Ch-13; Pp-169-170.

3. Lindeman A Carol; Mc.Athie Marylou; Fundamentals of Contemporary Nursing Practice; 1st Edition; Saunders Publishers; Ch-19; Pp- 465.

4. Wikipedia, the free encyclopedia