TelemedicineTelemedicine Extending Quality Health Care to

Rural Population.

Prof. Jayanta MukhopadhayDept. of Computer Science & Engineering.

IIT Kharagpur.

Two Contradictory Facts

A rural hospital in Hingelgange, North 24 Parganas, West Bengal, was almost without any doctor since its inception (1997).

IMA opposed introduction of new medical colleges in West Bengal, as many doctors did not have employment.

Reported around 2004

0%

10%

20%

30%

40%

50%

60%

70%

80%

Urban

Semiurban

Rural

Qualified Consulting Doctors.

Total No. of Doctors: ~ 5 lakhs.

0%

10%

20%

30%

40%

50%

60%

70%

80%

UrbanRural

Population Distribution

Total Population: ~ 1 billion.

Disproportionate Distribution of Medical Professional.

No. of doctors per town: 75No. of villages per doctors: 5Avg. No. of people served per doctor (in Urban area): 750Avg. No. of people served per doctor (in Rural area): 5750

Health Professional Statistics

0

100

200

300

400

500

600

700

800

900

1000

USA UK Russia China Cuba Malayasia India

Doctor

Nurse

Health Infrastructure in West Bengal.

01269Health Centers:

76131Hospitals:Public Private

Tertiary Center

District Hospital

PHC State General Hospital Subdivisional Hospital

Subcenters Subcenters Subcenters Subcenters

Which gets priorities in planning?

Lack of infrastructure.Non-utilization of infrastructure.Wastage of resources.

Telemedicine

• Providing medical information and services from distant locations.

• Evolution of Telemedicine -– Through postal system

– Using Telephone

– Using computers

Telephone Line

What is TelemedicineWhat is Telemedicine

Telemedicine may be defined as the use of computers and telecommunication technologies to provide medical information and services from distant locations

Applications in different forms

Information exchange between Hospitals and Physicians.

Networking of group of hospitals, research centers.Linking rural health clinics to a central hospital.Videoconferencing between a patient and doctor,

among members of healthcare teams.Training of healthcare professionals in widely

distributed or remote clinical settings.Instant access to medical knowledgebase, technical

papers etc.

Benefits of Telemedicine

Improved Access Covers previously unserved or underserved areas.

Improved quality of care Enhanced decision making through collaborative efforts.

Reduced isolation of healthcare professionals Peer and professional contacts for patient consultations and

continuing education.

Reduced costs Decreased necessity for travel and optimum uses of resources.

Why it is relevant to our society

Poor infrastructure

Non-availability of experts (disparate

distribution)

Low doctor-patient ratio (large population)

Lack of proper medical education Special attention required for Public Health Care System

Major Challenges

Poor Data Communication Infrastructure.

A Large Population Catered by Government Hospitals.

System Features should be scalable.

Cost of the system should be scalable.

How telemedicine could be effective?Which form of telemedicine is most appropriate?How our medical professionals would be motivated?

Different Strategies

PHC SubcenterPHC SHCPHC THCSHC THCTHC THC

What travels to a village?

Technology.Human Expertise.Training & education.

Technologies Involved

Medical Instrumentation Sensing Bio-medical Signals,

Medical Imaging, Measurement of Physical Parameters e.g. Body Temperature, Pressure etc.

Telecommunication Technology Trans-receiver on different communication

channels and network such as, on wired network, wireless medium etc.

Information Technology Information representation, storage,

retrieval, processing, and presentation.

LocalHealth Centre

LocalHealth Centre

RemoteHealth Center

RemoteHealth Center

Communication Channel

Communication Channel

Telemedicine: An Overview

• Availability of medical information at remote end.

• Discussion on the patient case.

• No patient transfer.

• Service Modalities– Store and Forward

– Real-time / Online Telemedicine

– Mixed Mode

– Mobile telemedicine / 3G Medicine

– Web based Telemedicine

Telemedicine : Using ICT

Digital camera

Referral Hospital

Nodal Hospital

PSTN/ISDN/VSAT link

Scanner

PrinterModem

Modem

Microscope and other medical instruments

Video Conference

Video Conference

Telephone

Telephone

•Modern Telemedicine systems

are developed on Electronic Health

Record (EHR) systems.

Referral Centre

Nodal Hospital

StateSwitching Centre

DistrictSwitching Centre

2 Mbps Optic

al Link

512 Kbps Leased Line

512 Kbps Leased Line

Schematic Diagram for Telemedicine using Leased Line

Doctor

Patient

Video and Data Conferencing

Multi-Reference in Tele-consultation

A center acting as local asks for tele-consultation with a remote center which can again be able to consult with another remote center.

If requiredconcerned datamay be resentto remotehospital

Patient

Local Hospital

Attending local doctor Remote Hospital 1

Remote Hospital 2

InternetInternet

Patient Console

Referral Hospital

Step 1. Upload Information

step2. Download Information

Step 3. Post Suggestions

Telemedicine Server

Step 4. Receive Suggestion

Telemedicine over web

Use of Mobile Devices in Telemedicine

ALR14:12 Attend Cardiac PatientPri = HiB.P. IncreasedLoc = Male Ward

Room-102,Bed-14BP =180/140 Tmp = 98 Pulse = 95 Hemoglobin = 8.3Dead Line = 20Minuts

ALR20:10 Attend a trauma pat in emerg. Pri = Hi. Unconscious.External BleedingDead Line = 10 M. Age = 30Y Sex = M.RR = 24 BP = 100/190 Pulse = 120 .

Emergency message for attending

a patient admitted in hospital.

Emergency Message for attending

a patient of accidental emergency.

Emergency Messaging

Exchange of Information at a Distance

VoiceImageVideoGraphicsElements of Medical RecordsCommands to a surgical robot

The Data ModelThe Data Model The Data ModelThe Data Model• Data related to a patient’s personal information• Data related to a patients medical information• Data for patient management in Telemedicine• Data related to the doctors• Data for system management

Telemedicine Systems: Developed at IIT Kharagpur

• TelemediK– TelemediK V1.0, V2.0, V3.3, V2004, V2005– A peer to peer application.– Facilitates specific care for different diseases such

as dermatology, hematology, orthopedics, pediatrics, oncology, cardiology etc.

– Online graphics communicator• Peer to peer discussion • Annotation of patient images and profile images.• Text chatting

TelemediK Model

• Based on peer-to-peer network topology.

• Physical transmission of patient medical records.

• Symmetry in tele-reference.

Limitations:•Duplication of records incurs increased storage cost.•May violate data consistency.•High bandwidth requirement.

Web based telemedicine system

• iMediK– iMedik V2007, V2008, V2009.– Client interfaces are mostly provided through

internet browsers. – Supporting care of same set of diseases as

handled by TelemediK.– Additional Diseases like HIV Pediatrics and

Drug resistant tuberculosis. – Online graphics communicator

• Conference among multiple participating doctors.

iMedik Model

• Based on the Central server model.

• Usually deployed at in the public network like WWW.

Four Layer Architecture

Limitations•No physical separation of records.•Needs higher configuration.•Security threats prevail.•Less or no fault tolerance.•Requires uninterrupted connection to external links.

Distributed Telemedicine System

• iMedik-D (Under development)

Referral Activities through a Central Server.

Hybrid Model: For some in-house patient management through the Central Server.

Hierarchical Distributed system (without any Central server.)

iMedikD Symmetric: Server Model

• Two types of nodes - main sever and peripheral server.– Multiple peripheral servers

connected to one main server.

– Deployment of hospital EHRs at peripheral servers.

• Symmetric patient referral

• Data segregation partially achieved.

iMedikD Model: Hybrid Server Model

• Combination of centralized server model and distributed server model.

• Supports both the scenarios– Organization that can not

afford the cost of a PS.• Example – H2

– Organization that can bear the cost of additional PS.

• Example – H1, H3

iMedikD Hierarchical: Server Model

• No central or main server.– Tele-consultation is carried

out in the origin server.

• Hierarchy of reference.

• Each hospital hosts a separate EHR system.

• Can be deployed in the public domain.

iMedikD Hierarchical: System Architecture

• A few additional services:– Manage telemedicine

network– Refer a patient.– Fetch doctors information.

• Only reference to data is sent with temporary log in information: – Securely.– Transparently.

`

Hospital A

ApplicationServer

DB

Web ProxyServer

OfflineDaemon

` `

Hospital B

ApplicationServer

DB

Web ProxyServer

OfflineDaemon

Mobile Healthcare

• Client interfaces for PDA and mobile phone.

• SMS based Emergency messaging system.

• Developing instruments with mobile interfaces.

Features of iMedik

• Multi-tier secure telemedicine system.• Focuses on service oriented approach.• Facilitates health care services through

Internet.• Salient features

– Encompasses all the features of TelemediK.

– Completely browser based interface.

– Complies with• HIPAA security standard

• EPR standard proposed by National Task Force for Telemedicine Standards, MCIT.

Summary of Patient Records

Visit wise patient record display

Patient record browsing

In the family hierarchy, parents are on the top and children are on the bottom. •Square represents male and circle represents female•Red stripe represents HIV+, and Blue stripe represents HIV- and no stripe represents unknown.•Half shaded circle represents step child. If left part is shaded then father is common else mother is common.•Thick border represents self (patient itself).

Family History

This graph plotsAge vs. BMI. The red line indicates the patient’s BMI. Other 3 lines indicate reference of WHO standard.

Growth Chart

Diagnosis

Decision support in prescription

Deployment of Telemedicine - Tripura

TelemediK 2005 deployed in 11 hospitals –

2 Referral Hospital in Kolkata

9 Nodal Hospital in different districts.

Deployment of Telemedicine – West Bengal

TelemediK 2005 deployed in 20 hospitals –

6 Referral Hospital in Kolkata

14 Nodal Hospital in different districts.

iMediK installed in Calcutta MedicalCollege in July 2009.

Conclusion• Telemedicine being increasingly used for

providing health care services.

• Effective and efficient in managing resources and time for delivery of health care.

• Telemedicine systems are evolving:

Peer to peer ► Centralized Server based ► Distributed Systems.

• Looking for a great healthy future of our public health care system in our country.