Introduction
With the advancement of technology comes the inevitable
combining of that technology with other areas of knowledge. In few fields does
the advent of the technological age bring so many reasons for excitement and so
many problems as in the field of medicine. Telemedicine has the potential to
provide great advances in the medical field. Instant access to information and
the creation of an international medical society could create a new era where
medicine is more efficient, more accurate, and available to all.
However, before this can become a reality issues
such as security of medical records, ethicality of medical diagnosis, and the
liability dispersion created by telemedicine must be addressed.
What is Telemedicine?
Telemedicine literally means “distance healing”
being derived as it does from the Greek word “tele”
meaning “distance” and the
Latin term “mederi” meaning, “to
heal”. It employs information technology, through the judicious use of
computers, related software, and telecommunication systems comprising of
compatible telephone lines, fiber optic cables and satellite linkups, etc., to
provide premium quality health care. Worldwide, people living in rural and
remote areas struggle to access timely, quality specialty medical care,
primarily because specialist physicians are more likely to be located in areas
of concentrated population (i.e in the urban areas). Due to the innovations in
computing and telecommunication technology, many elements of medical practice
can be accomplished when the patient and health care provider are geographically
separated. This separation could be as small as across town, across a state, or
even across the world. Broadly defined, telemedicine is the transfer of
electronic medical data (i.e high resolution images, sounds live video, and
patient records) from one location to another. This transfer of medical data may
utilize a variety of telecommunications technology, including but not limited
to: ordinary telephone lines, ISDN, fractional to full T-1’s, ATM, the
Internet, intranets and satellites. Telemedicine is utilized by health providers
in a growing number of medical specialties, including but not limited to
dermatology, oncology, and radiology, surgery, cardiology, psychiatry and home
health care.
History of telemedicine
Telemedicine has been in use in some form or the
other for over 30 years. The National Aeronautics and Space Administration
(NASA) played an important part in early development of telemedicine (Bashshur and Lovett, 1977). NASA’s efforts in telemedicine began
in the early 1960’s when humans began flying in space. Physiological
parameters were telemetered from both the spacecraft and the space suits during
missions. These early efforts and the enhancement in communications satellites
fostered the development of telemedicine and many of the medical devices in the
delivery of health care today. NASA provided much of the technology funding for
early telemedicine demonstrations. A book by Rashid L. Bashshur published in
1975 lists fifteen telemedicine projects active at that time. There were several
pioneering efforts not only in the US, but all over the world. A few of them are
worth examining briefly.
Space Technology Applied
Rural Papago Advanced Health Care (STARPAHC)
One of the earliest endeavors in telemedicine,
STARPAHC delivered delivered medical care to the Papago Indian Reservation in
Arizona. It ran from 1972-1975 and was conceived by the National Aeronautics and
Space Administration (NASA), engineered by NASA and Lockheed, and implemented
and evaluated by the Papago people, the Indian Health Service Department of
Health Service and the Department of Health, Education and Welfare. Its goals
were to provide health care to astronauts in space and to provide general
medical care to the Papago Reservation. A van staffed by two Indian paramedics
carried a variety of medical instruments including electrocardiograph and x-ray.
The van was linked to the Public Service hospital and another hospital with
specialists by a two-way microwave telemedicine and audio transmission.
Nebraska Medical Center
The Nebraska Psychiatric Institute was one of the
first facilities in the world to have closed circuit television in 1955. In 1964
a $480,000 grant from the National Institute for Mental Health allowed a two-way
link between the psychiatric institute and Norfolk State Hospital, 112 miles
away. The link was used for education, and for consultations between specialists
and general practitioners. In 1971 the Nebraska Medical Center was linked with
the Omaha Veterans Administration Hospital and VA facilities in two other towns.
The psychiatric institute also experimented in group therapy.
Video Requirements for
Remote Medical Diagnosis
In 1974 NASA contracted with SCI Systems of Houston
to conduct a study to determine the minimal television system requirements for
telediagnosis. The experiment was conducted with the help of a simulated
telemedicine system. First, high-quality videotape was made of actual
examinations conducted by a nurse under the direction of a physician watching on
closed-circuit television. This was the baseline for the study. Next, these
videotapes were electronically degraded to simulate television systems of less
than broadcast quality. Finally, the baseline and degraded video recordings were
shown (via a statistically randomized procedure) to a large number of physicians
who attempted to reach a correct medical diagnosis and visually recognize key
physical signs for each patient. Six television systems were investigated: two
systems were compatible with transmission over full bandwidth television
channel, while with the other four allowed more detailed investigation of the
frame rate and horizontal bandwidth required for each medical case. The
following four results were found: 1) statistical significance between means of
the standard monochrome system and the lesser quality systems did not occur
until the resolution was reduced below 200 lines or until the frame rate was
reduced below 10 frames/second; 2) there was no significant difference in the
overall diagnostic results as the pictorial information was altered; 3) there
was no significant difference in remote treatment designations as a function of
TV system type that would cause detriment to patients; 4) the supplementary
study of radiographic film televised transmission (25 cases) showed that no
diagnostic differences occurred between the TV evaluations and the direct film
evaluations for TV resolutions above 200 lines
if special optical lenses and scanning techniques were utilized.
The NASA SpaceBridge to
Armenia/Ufa
In 1989 NASA conducted the first international
telemedicine program, Space Bridge to Armenia/Ufa. In December of 1988 a massive
earthquake hit the Soviet Republic of Armenia. An offer was extended from the
United States to the Soviet Union for medical consultation from the site of
disaster in Armenia to several medical centers in the U.S. Under the auspices of
the U.S/U.S.S.R Joint Working Group on Space Biology, telemedicine consultations
were conducted using one-way video, voice, and facsimile between a medical
center in Yerevan, Armenia and four medical centers in the U.S. The program was
extended to Ufa, Russia to facilitate burn victims after a terrible railway
accident. This project demonstrated that medical consultation could be conducted
over satellite network crossing political, cultural, social and economic
borders.
The last ten years have seen a steady increase in
the number of telemedicine projects throughout the U.S and internationally. As
more funding became available in the early 90s (specially by the U.S
government), and as technology costs continue to decrease, telemedicine became
possible for a wider spectrum of users.
TeleMed
The advanced Computing Laboratory at Los Almos
National Laboratory, Los Alamos, New Mexico, developed TeleMed, an electronic
medical record for managingtuberculosis patients through collaboration with the
National Jewish Center for Immunology and Respiratory Medicine in Denever,
Colorado. Telemed provides a snapshot of patient data, presented chronologically
with access to laboratory test results, clinical history, radiology images,
reports and treatment history. A particularly valuable feature allows physicians
to annotate the medical record, either orally or in writing, for collaborating
physicians to retrieve. Medical expertise can also be exchanged in real time,
with both users sharing the same screen and with each having the capability to
drive the mouse-pointer. Telemed now available in the Internet using Java based
technology enables physician specialist to
Support primary care providers in the management of complex medical
problems. The technology creates a “virtual patient record” that allows the
integration of databases from multiple clinics and multiple providers across
geographically separated areas. This permits individual health care facilities
to continue to own and manage their own data while making the data accessible to
others treating the same patient. TeleMed provides
a time-oriented record of the patients medical history but only retrieves the
actual data on demand, thereby minimizing the bandwidth requirements of the
network capabilities. Distributed ownership of the data means that only one copy
of the data exists, and the copy remains where it was located.
Types of technology
Telemedicine
is an application, not a technology, although the term is often misapplied. Two
different kinds of technology make up most of the telemedicine applications in
use today:
(i)
Store and forward
technology
(ii)
Two way interactive
television (IATV)
Store and forward
technology is used in Telemedicine for transferring digital
images from one location to another. A digital image is taken using a digital
camera, (‘stored’) and is then sent (‘forwarded’) to another location.
The image may be transferred within a building, between two buildings in the
same city, or from one location to another anywhere in the world.
ACR (the American college of Radiology) and NEMA
(the National Electrical Manufacturers Association) formed a joint committee to
develop a Standard for Digital Imaging and Communications in Medicine.
The DICOM Standard was developed according to NEMA
Procedures. It is developed in liaison with other Standardization Organizations
including CEN TC251 in Europe and JIRA in Japan, with review also by other
organizations including IEEE, HL 7 and ANSI in the USA. Teleradiology,
Telepathlogy and Teledermatology are the most common application in use today.
Interactive
television (IATV) is
used when a consultation between the patient, primary care provider and
specialist is necessary. Videoconferencing equipment at both locations,
typically an urban and rural location, allow a ‘real time’ consultation to
take place. This means that the patient does not have to travel to an urban area
to see a specialist, and in many cases, provides access to specialty care when
none has been available previously. Almost all specialties have been found to be
conducive to this kind of consultation including psychiatry, internal medicine,
rehabilitation, cardiology, pediatrics and gynecology and many more.
If
telemedicine is being used today, where is it?
1. By video, e-mail, telephone etc, consulting with doctors across, state, national, and international
borders is now being done everyday. This teleassistance is rapidly growing.
2. Video conferencing for diagnosing or educational purposes. A doctor
in one hospital can talk with a patient or doctor in another area to speed
diagnoses and their accuracy. A surgeon can watch a procedure remotely and
consult to make sure things go smoothly. Medical school students can learn
medical procedures without having to be in the operating room.
3. Sites containing medical information are popping up on
the web every day. One can go to find information on a certain condition or
treatments, read up on medical interests, buy products, or even visit a “cyberspace
telemedical office”.
4. The use of telemedicine to reach undeserved areas
such as rural sections of the country or military bases in other countries is a
huge area being researched now. The benefits of these services could be
amazingly far reaching.
5. Remote supervision of physicians’ assistants or nurses can be done
by means of telecommunications.
6. A highly controversial, but possible, use of
telemedicine for the future is the establishment of large
medical records databases.
7. An already extremely common use of telemedicine
today, research databases such as
Medline make medical research infinitely more efficient than before.
Benefits of telemedicine
The benefits of telemedicine are many. Instant access to information, whether it is about a certain patient
or a certain topic, can be essential or even life saving. The Telemedicine
Research Exchange notes the story of a rural doctor who had never done an
amputation before being helped through the procedure by a well-practiced
physician over a video link. The two saved the life of the amputee, who did not
have enough time to reach the larger facility.
A multifold increase in efficiency
for all types of medicine is another large benefit. Travel times for
patients and doctors could be significantly reduced as well as research time and
“paper handling” of medical records.
Accuracy of diagnosis is always a major concern for the
medical community. With telemedicine it will be easier for a doctor to get a
“second opinion” on their diagnosis of a patient. With greater access to
help, more patients will be treated correctly, the first time. This leads to
more benefits like quicker average
recovery time, less usage of needless medicines, and reduced costs to patients
and hospitals.
Self-help will increase with the online availability of so
much medical information. Informed
patients can result in eliminating needless visits to the doctor, patients
will be better equipped to express symptoms to the doctor when they go.
Telemedicine promises the day of individualized care guidelines for the ill and easier long-term
monitoring of chronically ill patients.
Better reaching
geographically difficult areas, such as the rural communities is one of the
most important promised benefits of the telemedicine age.
Improvements in everyday medical research have already been seen. Searching a topic for
clinical or educational purposes is amazingly simple and requires only a
fraction of the time the same research used to take.
Telemedicine in India has not taken off, as it
should have; this is mainly due to poor telecommunication facilities, high
costs, non-availability of medical records in digital form.
Apollo
Hospitals group based in Chennai has plans to set up 3,200 telemedicine centers
in India by late 2001. According to the Apollo Chairman, Dr. Prathap C. Reddy,
the speed with which the centers will be established will be determined by the
speed of the infrastructure development in the country. They hope to eventually
connect 2,600 primary care centers, 500 secondary care centers and at least 100
tertiary care centers all over the country. They have recently linked the
Aragonda village (pop. 15,000) in Andhra Pradesh with Apollo Hospitals at
Hyderabad and Chennai. A primary care facility was established in the village,
which will be connected to the Apollo Hospital. Since 80% of the population in
India is rural and 80% of the medical community live in urban areas, it means
that access to healthcare is limited for many rural inhabitants. Apollo hopes to
provide a successful working model of telemedicine which will also allow for
implementation of population control programs, create a channel for AIDS
awareness, bring the private insurance sector initiative to the rural
population, and be used for epidemiology monitoring. (Source: Business Line, June 22, 2023)
An Event Recorder (ER) is small electronic
equipment resembling a TV remote control; it has no cords attached to it. The
patient simply has to place it on his chest, push a button and wait for a minute
for recording the ECG. This done he has to dial the telephone number of his
doctor and place the equipment on the mouthpiece as per directions given, and
press the same button again. The ER converts the electronic signals into audio
signals, which again get converted into electronic signals on the doctor’s
personal computer. The ER has been tested on domestic flights, in moving
vehicles, offices and parks. It has worked to the satisfaction of the medical
experts.
The Escorts Heart
Foundation in Delhi to provide assistance to patients is using the ER, the
services are available in Gujarat also.
EHAS
is first of its kind in India, which opens a new dimension in providing instant
cardiac attention. It's a development in cardiac telemedicine that has already
been proven across Europe and USA where it has FDA approval.
It
operates 24 hours a day, 365 days a year. A newly commissioned Heart Command
Centre (HCC) backs EHAS and a fleet of mobile cardiac cares ambulances. This
will provide the highest possible level of critical lifesaving service
unparalleled in our country before.
New Search Engine
The Telemedicine Information Exchange (TIE)
programmer, Burt Jurgens has developed the Telemedicine Search Engine (TSE) which
will greatly increase the telemedicine information searching power for TIE
users. Enter a search item in the TSE field (found on the home page http://tie.telemed.org),
and your term will be searched in over 60 telemedicine related sites, which are
currently linked to from various places on the TIE. Using this search engine one
does not have to qualify any of the terms with the word “telemedicine”, as
the searching will be done only on the telemedicine web pages.
GUIDELINES FOR THE IMPLEMENTATION OF A TELEMEDICINE
PROGRAMME
Sensitizing
In sensitizing government decision-makers, health
and telecommunication
professionals, concerned communities and users, the following points
should be highlighted:
1.
Telemedicine is not
meant to replace the physician;
2.
The value of
telemedicine lies in spreading medical knowledge, through
the use of telecommunications, to remote areas where it is not available;
3.
No sophisticated
communication infrastructure is required in order to develop telemedicine
applications.
Evaluation of the
present situation
1. Both sanitary and communication infrastructure
should be evaluated.
2. The evaluation of sanitary infrastructure should
cover the existing problems, needs and priorities, as well as the geographical
distribution of the primary, secondary and tertiary assistance centres.
Consideration should be given to communication infrastructure; the links
currently available and future expansion plans.
Creation
of interdisciplinary groups
1. Working groups should include members from the
health and telecommunication sectors, as well as other sectors that may be able
to share the structure to be developed (e.g. education, tourism, production).
Integration
of telemedicine
The
telemedicine programme should not be isolated, but must be made part of the
global health project.
Training of health professionals
Health
professionals should be aware of:
1. Available
tools;
2. Applications
that can be developed;
3. How to
develop such applications;
4. How to
use the applications developed.
Implementation of pilot projects
1. Identification of
a project-leading group;
2. Identification
of existing problems;
3. Definition
of quantifiable and verifiable objectives;
4. Selection
of technology (physical links, types of equipment and systems to be used, as
well as possible combinations thereof);
5. Definition of
the cost of the infrastructure: cost of initial installation, cost of operating
the system and cost of its maintenance; evaluation of the cost/benefit ratio of
the different systems.
6. Comparison with
reference models of existing projects (benchmarking); when developing a project
on distance medical education (tele-education), there is also a need for a
project-leading group to be responsible for providing valid content on a
permanent basis; organization of the pilot project into phases, with an
individual programme for each phase; monitoring and evaluation of the projects.
It is important to verify the number and type of applications developed, the
number of users, the level of diagnostic quality, the amount saved by the use of
telemedicine (in terms of transportation, unnecessary procedures, etc.);
feedback between designers, operators and users of the project in order to allow
the necessary adjustments/corrections; assurance that the project is
sustainable; identification of funding sources to get the project started and
keep it going.
7. Telemedicine
and the national health plan. Based on the results of the pilot projects, it
should be possible to generate specific application models to be included in the
national health plan.
8. Education for telemedicine. It is of crucial
importance to introduce telemedicine into formal health education programmes.
Need
for resource optimization
1)
There are multiple applications running on low-cost and high-availability
links such as radio, telephony, Internet, etc. Given the shortage of resources
and the need to share those that are available with other priority projects, it
is essential to carefully explore the possibility of using low-cost links before
adopting high-cost solutions.
2)
It is important that the systems adopted use configurations
that
are suitable for future upgrading.
3)
The
mix of technologies and formats serves to optimize the quality and
use of the applications. Resources should be used in a flexible way in
order to achieve the maximum benefit at the lowest cost. Examples:
Cross-consultation: The Internet could be used for administrative aspects such
as identification of specialists, making appointments, sending medical records,
etc., with a facility like ISDN being used only for discussion of the case
itself.
4)
Education:
Even though tele-education systems are available, videoconferences, courses,
etc. could be recorded, allowing them to be
multicopied, made available through the Internet, etc., and distributed
to a
much wider audience.
5)
To
optimize the use of resources, the organization of regional or subregional
projects should be promoted.
6)
The
need for setting up demonstration centers in leading hospitals laboratories with
terminal equipment that is compatible with technology in the developing
countries.
7)
The
need to enhance participation by health sector delegates, since
they are familiar with needs.
Telemedicine,
do we need it in India?
The purists will argue that in a country where
clean drinking water is not available to a substantial percentage of the
population, malaria eradication still a distant dream, Tuberculosis
is rampant and
epidemics kill thousands
every year. We have
difficulty in
providing adequate power in the form of electricity
in even the leading urban areas. In such a grim situation what would be the
benefits of telemedicine? And what should be the priority accorded to it?
The
advances in technology can neither be ignored nor denied. Few could have
visualized the impact of Internet and the wide acceptability it enjoys today,
the telecomm services are far superior to what they were a decade ago.
Telemedicine is therefore required; it is relevant as well as necessary for our
country. The medical expertise is concentrated in the major urban cities; the
benefits of their expertise should filter down to the unfavoured areas, like the
rural sector, where the medical practitioners are unaware of the current
advances
Medical Transcription
With medical expenses being very high in the USA, most patients
cannot afford to pay from their own pocket. Therefore, the majorities rely on
medical insurance to take care of such expenses. In order to claim the money for
services rendered, doctors and hospitals first need to submit detailed reports
to the insurance companies.
Preparing such extensive reports on every individual patient would
prove to be too time consuming for the medical professionals and facilities.
Therefore, physicians and other healthcare professionals simply record the basic
information about every case on digital media or tapes. The dictations are then
sent to professionals who are trained to go through, interpret and structure the
dictations into full fledged reports comprising patient assessment, therapy
diagnosis, procedures, etc. This process of converting dictations into reports
is called Medical Transcription, and the professional who specialize in this
IT-enabled service are called Medical Transcriptionists. The job requires
excellent listening skills, accurate typing ability, good written English, and
extensive knowledge of medical terminology.
Initially, most Medical Transcription jobs used to be outsourced from Mexico, Israel and Ireland. While Mexico did not possess sufficient English speaking professionals, the others charged a lot for their services. Thus, the focus shifted to the Indian subcontinent and Philippines. Today, India with its large pool of English speaking population, ideal virtual time difference with USA, and modern telecommunications network, is busy emerging as the new MT hub of the world. Promising ample career opportunities to those keen to take up this IT-enabled profession
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