TELEMEDICINE INDIA

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Title: TELEMEDICINE INDIA
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By Kumar Venkat, Surya Technologies Inc.
The power of technology and market forces to solve the central social problem of our timesthe extreme poverty and deprivation of sections of the population in every part of the worldhas become almost an article of faith. In fact, the idea of closing the digital divide is now at the
core of major poverty reduction efforts.
The information technology industry, having nearly sated demand in the developed countries,
is naturally eager to create new markets elsewhere. Political leaders in many developing
nations, having failed to address poverty in their countries, are grasping at new technologies
and global trade as their last, best hope to raise their large populations' standards of living.
Consequently, business executives and government officials are often on the same side of this
issue, backed by powerful international agencies such as the World Bank and the World Trade
Organization (WTO).
Frequently missing from policy statements, business initiatives, and other poverty reduction
proposals, however, is an accurate understanding of what technology can do. A critical
question is whether the digital divide is a cause of poverty or an effect of the underlying social
and economic divides.
The United Nations Development Program (UNDP) is the premier international agency
dedicated to fighting poverty. In its Human Development Report for 2001, it asserted that the
technology divide does not have to follow the income divide. But the evidence to date shows
that the current technology divide has consistently followed the income divide all over the
world.
More than 96 percent of computers connected to the Internet are in the wealthiest nations,
home to 15 percent of the world's population. Nearly 60 percent of the U.S. population has
some access to the Internet, a distribution that is highly correlated with household income. In
India, less than 0.5 percent of the population has Internet access-which translates to about
five million people with high enough income levels, education, and computer skills in a country
of one billion people.

It is also instructive to look beyond access to technology and focus on outcomes. The latest
U.S. economic boom was fueled in large part by new technologies. But in spite of all the
prosperity and proliferation of technology, the national poverty rate remains above 11 percentessentially where it was before the computer revolution in the mid-1970s. Nearly 40 million
Americans lack health insurance and over 15 percent of children are growing up in poverty.
Technology and market forces have clearly stopped short of addressing poverty in the United

States, and not surprisingly, they have stopped at the point where there is no profit to be
made.
Moreover, the income gap between the rich and the poor in the United States has expanded
by almost 50 percent over the last quarter century. The implication is that, as market forces
propagate new technologies, people who are already doing relatively well are likely to benefit
the most, reinforcing long-standing economic disparities. The digital divide is thus an effect and
manifestation of these disparities in wealth.
The United States, of course, is a "best case" example. Poverty in developing countries is far
broader and deeper. Most of the 1.3 billion people surviving on less than a dollar a day live in
developing countries. Given the United States' failure under the best of economic conditions to
eliminate poverty within its own borders, is it reasonable to expect that developing countries
could use the same tools-technology and markets--to root out the same problem on a much
larger scale?
The UNDP Report, to its credit, acknowledges that technology is created in response to market
pressures, and not the needs of the poor. Markets, in turn, are driven by the investments and
consumption patterns of the affluent sections of society. In many cases, technologies have
been developed to make life comfortable and convenient for those who are not worrying about
their next meal or wondering how to get medical care. Much of the recent focus on poverty
reduction has been on applying these technologies of convenience to situations where
fundamental human needs have yet to be met.
This is not to say that people in poor countries have no use for modern technologies or that
market-based approaches cannot play a role in a broad attack on poverty. In Bangladesh, one
of the poorest countries in the world, Grameen Bank has successfully used micro-credit to
encourage entrepreneurship in several thousand villages. In each village, an entrepreneur
purchases cell phone service from a subsidiary of the bank, and operates a pay-per-call
service that in effect connects the whole village to the telephone network. These small-scale
enterprises have turned a profit in most cases, and loan repayment rates are very high.

The digital divide seems quite meaningless for the multitudes everywhere who lack
essentials like adequate nutrition, primary health care, basic education, safe water, and
sanitary living conditions
While the program is quite small, Grameen Bank's experience suggests that micro-credit could
work in poor countries, often at the level of just a few hundred dollars. The challenge is in
applying innovative approaches like this on a broader scale without getting caught up in the
hoopla surrounding new technologies and globalization.
Alvin Toffler, the futurist, has urged combining the idea of micro-credit with "micro-trade." He
envisions poor people in small villages using the Internet to "identify markets 10 thousand
miles away" for small amounts of agricultural products or crafts.
The obvious problem with this argument is that it requires people who might not even be
literate, let alone computer savvy, to make sophisticated use of the Internet for marketing and
sales over long distances. Moreover, while it is easy to send information around the world
through the Internet, it is inefficient and complicated to ship large numbers of small packages
everywhere, especially from hundreds of thousands of small villages often deficient in
transportation infrastructure.
Gurcharan Das, a former business executive and now a venture capitalist in India, proposes in
his recent book India Unbound (Alfred Knopf, New York, 2000) that, in the "globalized open
economy governed by the WTO," developing countries like India should make only what they
are good at and import the rest. As an example, he suggests that a little software could buy a
great deal of a generic commodity like steel.
But what about the hundreds of millions of Indians who are producing other things and have no
chance of participating in this trade regime? Global trade is no substitute for building diversified
and healthy local economies.
Are the poor a business opportunity?
The digital divide is a major concern to technology companies, because it bars billions of
people from buying their products. But it is difficult for industry to tap this market potential

without addressing poverty as an issue. Microsoft chairman Bill Gates has publicly stated that
he does not see the rural poor in developing countries as a significant business opportunity.
Hewlett-Packard, believing it can "do good while doing well," has responded more positively.
Its World e-lnclusion program is a plan for working with local partners on applications that are
"appropriate and relevant" in areas like telecommuting, e-commerce, and financial services. It
remains to be seen how bottom-line pressures will influence the choice of applications.
Moreover, some of the applications the company is interested in, such as "e-jobs" based on
global telecommuting, seem appropriate only for those with fairly high levels of education and
skills.
The technology divide is real for those who have moved beyond obtaining the basic
necessities of life and are held back by lack of access to technology. Bridging the divide might
well make a big difference to this section of the population, while bringing new revenues to
technology companies.
On the other hand, the digital divide seems quite meaningless for the multitudes everywhere
who lack essentials like adequate nutrition, primary health care, basic education, safe water,
and sanitary living conditions. Access to information technology cannot be useful unless such
needs are also met at the same time. Even if a primary school in a village is equipped with
computers, a child will not benefit if she is malnourished, if her parents are struggling to make
a living, or if her family cannot get medical care.
Any serious solution to such deep poverty will necessarily have to reach beneath the digital
divide and confront the underlying disparities in society. Ultimately, the nature of the problem
should dictate the solution. An age-old human problem like poverty suggests a people-centric
approach that is built around meeting the needs and aspirations of human beings, using
whatever technologies are appropriate and sustainable. Society must find ways for the poorthe landless laborers and subsistence farmers in rural areas, the low-wage workers living in
urban slums--to earn a living wage and supply their own needs with a measure of dignity.
This would take nothing less than a paradigm shift in how we view and tackle poverty in this
age of information and globalization.

TELEMEDICINE:
WHAT, WHY AND FOR WHOM

Subhash Joshi
sureq<& icenet.net
INTRODUCTION
Telemedicine is very much in vogue these days. There are ’n' number of popular articles in newspapers and magazines, just as there are several
technical articles on the subject. There are many meetings, conferences and workshops on telemedicine. The number of websites —both Indian
and foreign- has to be seen to be believed. But in spite of all these, the concept is somewhat diffused and vague. There are apparently different
levels at which telemedicine is understood and practised. This article attempts to discuss telemedicine in the overall context of India. Telemedicine
is basically an application of communication technologies for medical purposes and hence it is necessary to examine both these contexts of
communication and heaith/medicine.

Tne present communication revolution has two major aspects: (1) Its very rapid expansion alongside its user-friendly nature and (2) merger or
convergence of several different communication technologies. Tne way radio and television has spread in the last couple of decades makes the
point of widespread use very apparent. The spread may not be uniform. The developed countries have a far greater access than the developing
countries. But even in the latter countries, the spread has been no less phenomenal. For example, a country like India has as many as 75 Million
television households. The case of persona! computers (PCs) illustrates the user-friendly nature of technology. The PCs have become so userfriendly that even small children can operate it with ease. These different media, however, do not any more operate in isolation.
There has been a remarkable convergence of different media of communication. The Internet is a classic example of this. It combines the features
of mass media, telecommunications and computers. It is no longer just a sum of different technologies. It is a new communication technology with
• unique features of its own. All this has openeci the doors for a variety of applications. Telemedicine is one such application.
WHAT IS TELEMEDICINE

The term "telemedicine" is derived from the Greek 'te//y meaning 'at a distance'nvd from the Latin 'mederi meaning 'healing. In its simplest form
telemedicine means enabling people in one geographical area to have access to a trained medical specialist in another geographical location.
Understood in this mode telemedicine can be of a very simple nature or can assume a very complex form depending upon the purposes and the
types of technologies used.
Teiemedicine understood in this simple form is reaiiy nothing new. Medical advice through correspondence, letter, etc. has been in practice for
several years. Doctors providing tips on diagnosis or treatment of ailments through newspaper columns or through radio and TV broadcasts also
hardly need a reminder because they are so widespread. Telemedicine through correspondence involved considerable time lapse between the
patient's query and the advice of the doctor, but protected the privacy of the patient. Telemedical advice through the print media made it more
. widespread, but ceased to be one to one. The response to the queries through radio and TV broadcasts accelerated the spread of information and
like the newspapers had the 'advantage' of being both specific to the query as well as it being shared by other members of the audience.

A more basic change occurred when the phone-in programmes on radio and TV became popular. The patient can directly call on to a doctor in the
studio and the advice could be given live and in an interactive mode. Since it is in the broadcast mode, other members of the audience can hear
both the query as well as the advice. Here was a combination of the medium of telecommunication and mass media, which saved time and
extended the reach. Radio and television broadcasts can also be categorised as a form of telemedicine.
Telemedicine these days, however, is not understood in its simpler form. It would mean something significantly more than a mere dialogue
between the patient and the medical specialist. The complexity has become possible because of the new communication technologies. They have
become faster, more widespread and more independent of geographic locations.
Teiemedicine is a system of health care delivery in which the physicians examine distant patients through the use of telecommunication
technoiogy. This communication bridge can take several different forms. It can be live or it can be offline. It can be deiivered via a two way
interactive audio and video mode or two way time delayed, stored and forward multi-media electronic mail. Basically it means that the patients'
data ranging from description of the symptoms in a text form or medical data in the form of simple X-rays and electroencephalograms to more
advanced angiograms, magnetic resonance images, and histopathology slides can be transmitted from a distant location to the medical specialist
located practically anywhere in the world. The specialist studies all these medical data and conveys his diagnosis and the treatment to the patient
through the doctor at the patient-end. This also may happen through live interaction or on the off-line mode.

WHY TELEMEDICINE
Telemedicine is used for a variety of purposes. Some of the more common purposes include: (1) Remote consultation; (2) Second opinion; (3)
Interpretation services; (4) Continuing education and exchange of clinical information; (5) Home care and (6) Online surgery in some very rare
cases. Of all these, the first three are the more common uses of telemedicine the world over. Telemedicine is open to a variety of medical
specialities such as cardioioqy, pathology, neurology, psychiatry, dermatology, opthalmology, oncology and practically every other branch. It is also
useful for emergency care, liome health care and distance education.

One of the advantages of tele-education is that it can reduce excessive demands on the health care system by focusing on prevention. If the
people are empowered through tele-education, it helps in creating a physically and mentally healthy society. Tele-education can take three major
forms: (1) Continuing distance education, (2) Community health education, and (3) Access to remote information. The medical specialities to which
telemedicine will be applied and for which specific purposes it will be applied should depend upon the needs of the community, availability of
infrastructure and availability of medical professionals.
Since India's independence from the British rule in 1947, the country has made significant progress in several areas including health. For example.

Smallpox has been completely eradicated, the infant mortality rate has been brought down, life expectancy has gone up, pre and post natai care
facility has improved and there is overaii progress in disease control' and establishment of modern health infrastructure, there is extensive network
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staff available and a very significant indigenous capacity has been established for production of drugs, vaccines, hospital equipment, etc. Yet a lot
remains to be done. There is scope for improvement in practically every area of health care. India’s rank is still above 100 in terms of the overall
health system performance. The peri-natal mortality rate is about 46 which compares very poorly with some of the other Asian countries like Sri
Lanka (25), Thailand (20) and not to speak of developed countries like Japan and Singapore (5 each). The ratio of doctors to population is also
very poor. In developed countries there is one doctor for every 500 persons. In India this ratio is one to 15,500.
' What is even more significant in India is the stark contrast that one sees in the health status and the availability of infrastructure. Advanced
medical services, highly trained medical doctors, modem medicai equipment, etc. are avaiiabie in some or the other part of the country. There is a
sizeable section of population enjoying very high level of health status and medicai care. The overall health indicators have also gone up
significantly in some sections of the society. If one were to look at the urban areas and the rural areas, the stark contrast becomes very obvious.
The big metres and towns will have the most advanced facilities available while the villages do not have even rudimentary services available. It is
in a situation of such stark contrast one has to see the applicability and usefulness of the telemedicine programme.

TELEMEDICINE FOR WHOM
Telemedicine to be really useful in India would mean to reach the unrelated rather than merely enhancing the facilities of those who already have
better means of obtaining medical services. If telemedicine is merely going to serve the needs of a few rich patients in cities like New Delhi and
Mumbai, it will have little relevance. This is not to say that these segments should not have these facilities, but only to underline that they already
have such facilities avaiiabie and tney couid afford co have teiemedicine not only within the country, but even with the best of super specialists in
any other part of Lite worid. Telemedicine, therefore, for urit, purpose will be discussed only from the perspective of tire unreached wlro are in need
of specific interventions.

It can be clearly seen from the discussion so far that certain amount of infrastructure/facilities is pre-requisites of telemedicine programme. These
include! minimal availability of medical/para-medical staff, availability of electricity, availability of communication lines like telephone, availability of
elementary hospitals and clinical investigation facilities are a must. This contrast creates a dilemma. Looking at the Indian conditions, if you look
for a place with this minimal infrastructure, one also sees that there are doctors avaiiabie. In other places you have neither doctor nor the
infrastructure and facilities avaiiabie. This creates a peculiar condition. Efforts, however, have to be made to overcome this contrasting situation. It
is true that there is shortage of facilities, but it is not as if nothing is avaiiabie. It is true that a village or a group of villages may be such where no
facilities are available. But many of them will be available somewhere in the district place usually not very far from the villages. Some hospitals,
either government, private or charitable trust owned, is available in any district town. A reasonable number of medical staff and associated medical
facilities sre also available in these towns. So telemedicine facilities (patient end) will have to be created in some such district towns. Patients from
the nearby villages any way visit these hospitals and may have to come for tele-medical purposes also. These patients end can be linked to super
specialist end in any other part of the country/world (where the best of doctors would be available) and interaction can be established between
these two ends. Telemedicine can be expensive in the initial stages, but over a period of time as the technologies develop, the human power gets
used to using these facilities, the cost will gradually decrease.

Telemedicine is able to overcome some of the identified barriers of delivery of specialist health care. Some of these barriers are lack of proper
public transportation, large distances, travel time and cost, waiting time after having reached the hospitals, lack of economic means and non
availability of trained medical doctors especially specialists and super specialists.
There have been quite a few efforts to use telemedicine but these are usually restricted to bigger metro and towns cities. These have taken place
at the initiative of the private parties. There are stray examples of charitable institutes using this technology; there are a large number of health
web sites in India. But in all this, there is very little of planned, goal-directed teiemedicine intervention programme to meet the requirements of the
needy. For the teiemedicine programme to be effective and ’successful in India, the following criteria wiii have to be met:

1.

It should benefit the unreached

2.

It should benefit a larger community

3.

Medical data transfer be error-free and reliable

4.

Medial technology should be user-friendly

5.

There should be a complete system — properly equipped patient-end, super specialists, links, etc.

6.

There should be proper storage and retrieval system for the medical data

7.

The medico-lenai provisions should be thoroughly thought through

8.

Its economic sustainability should be looked into from the beginning

9.

Maintenance aspects are important but often neglected at the planning stage. This can lead early death of the project after birth

10. It should be able to meet the felt and obser/ed needs of the community

DECU’s EFFORT
Telemedicine clearly has enormous utility for a country like India. Care has to be taken that it does not remain confined to a few well-to-do
patients in big metros. Given the scarcity of medical facilities in rural areas, efforts will have to be made to take this technology to these areas as
the majority of Indians reside in the villages. Market forces alone will not meet their needs. There will have to be a planned intervention

programme dedicated to this end. Development and Educational Communication Unit (DECU) of Indian Space Research Organisation (ISRO) is now
trying to set up a needs based teiemedicine project in different parts of the country. ISRO has recently initiated a GRAMSAT (’satellite for villages')
programme. It is aimeu at reaching out to the viitages for development and educational purposes. A variety of satellite based
leuinuiogies/appikdtions will be used for this purpose.

Cne of the major applications programme under consideration is that of telemedicine. DECU proposes to initiate it in three or four states wherein
links will be established between remote rural areas to specialist ends. Detailed monitoring, feedback and evaluation studies have been planned.
The progress and achievements of telemedicine should be of interest to all, especially in the developing world.

W 3^2
' Challenges in Development of an Integrated Telemedicine System in a Developing
Country The Indian Experience
Saiijay r. Sood 1 & R.S. Khandpur 2
Centre for Electronics Design & 1 echnology of India
A-34, Phase 8, Industrial Area, SAS Nagar, INDIA.
1 System Engineer (Project Telemedicine)
2 Director

Centre for Electronics Design & Technology of India, SAS Nagar, India was awarded a project “Development of
Telemedicine Technology” by Ministry of Information Technology^, Government of India. The primary’ Objective
of the project was to link three premier medical institutes of North India for practicing Telemedicine initially for
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The development of the integrated telemedicine system - Sastjeevani in a developing country’ like India was a
challenging task. All the components of telemedicine namely Telecommunications, Medical Technology and
Health services infrastructure posed rather unexpected challenge. The objectives had to be disintegrated into
smaller modules in order to keep the deliverables within sight. This strategy met the targets both timely and
precisely. Some of ine challenges those were addressed during the development process were :
o The design and the approach towards the development had to be such that would not dislocate the existing
pattern of working regarding patient records.
o Initial development and modular testing and trials had to be limited to I,AN as the communication service
provider needed their time to install the lines.
The communication services (mainly ISDN) provided by the service provider were not in tune with the
technology that was being offered, primarily because of the lack of experience.
o The development had to be done keeping in mind cost vis-a-vis ultimate objective i.e. this pilot study had to be
planned for a tertiary level institute whereas eventually the technology was to be adopted for the peripheral
institutes with limited resources (both professionally and financially).
o Medical peripheral devices being used were PC based as against the stand alone devices which the medical
professionals had been using ever since. This was to be ensured so the adaptation by the medical fiatemity
easy.
o The design of the system had to be cost effective and this lead to the selection of a conventional relational
database management system for image storage and retrieval as against the necessity’ of having a P ACS based
system.
o Since the prevalent infrastruebure does not support inclusion of Telemedicine facility at the medical institutes
at the developmental level, concept of a centralized Telemedicine facility7 was preferred for all the applications
of Telemedicine.
Tlie challenges faced., no doubt typically reflect the developing world’s culture. The paper will address the
challenging issues faced during the development and implementation phase and the strategy adopted to overcome
the problematic issues.
Te!eme<!*€!ne: Hype ¥s realty

Dr Saji Seiam
. .VWAMM*...

Many hundreds of consultations have taken place since HealthNet began operating in June 1990. The
secotHJ of tliese consultations — and one of the most dramatic io date — involved d baby named Aida
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Porras. Less than an hour after she was born in Alpine, Texas, she began to have what doctors call
"severe respiratory distress"— in other words, she could barely breathe. Her doctor, lames I uecke,
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^.:>Simmediate!y contacted HealthNet in Lubbock, more than 500 kilometers away. In minutes, he and Dr

Marian Myers, a neonatoiogist, were reviewing the baby's X-rays and lab work. Dr Myers decided that
Aida had aspiration pneumonia and told Dr Luecke how to counteract it. Within two hours, Aida was breathing
comfortably.
TeteDoc designed and manufactured by Texas Tech's Health Sciences Center, is a self-contained, portable unit
about 1.5 meters tali and one meter wide. Setting it up at the piace where the patient is being examined is simple:
just plug in a power cord and a telephone cable. On top is a small camera with a remote control that makes it pan,

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< throats, joints, and internal organs. A large high-resolution monitor shows the patient at both locations — and a
smaller one shows the consulting specialist. A microphone picks up ail conversations. Inside TeieDoc is also a
lightbox that allows transmission of X-ray images and a video cassette recorder for documenting the consultation.
Designers are working on a TeieDoc Junior, a unit designed to be the size of a briefcase that could be carried in
' ambulances or a doctor's car.

This is the kind of technology which is written about nowadays when it comes to telemedicine. This article explores
some of the myths and realities associated with telemedicine and examines where our healthcare providers stand
with regard to some or the developments in this space.

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

What is telemedicine?
According to a Japanese definition in 1996, "it the use of any electrical signal to transmit medicai information". In a
JAMA paper in 1995 telemedicine has been defined "as the use of telecommunications to provide medical
information and services. It may be as simple as two health professionals discussing a case over the telephone, or
as sophisticated as using satellite technology to broadcast a consultation between providers at facilities in two
countries, using videoconferencing equipment".
A broader definition from University of Virginia is "the use of telecommunication technology to deliver healthcare
services and health education to sites that are distant to the host site or educator." The American College of
Radiology has however defined the detailed ACR standard for teleradiology, which includes definition of
teleradiciogy, besides goals, qualifications, qualification of personnel, equipment guidelines, licensing,
communication, quality control.
Appiications
Clinical applications could be utilized in the following areas effectively, though one could argue that telemedicine
could be used for any specialty, like cardiology, radiology, homecare, pathology, endoscopy, nephrology,
ophthalmology, surgery and emergency care. Many of these have specific applications and interfaces built around
these specialties, which differentiate them from generic telemedicine applications.

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

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

Trave! time/ cost: There is a shortage of specialist/ super-speciaiist prcfessionais in India, especially in rural areas.
It might not be good time management on the part of the specialist to travel all the way to the rural areas without
having enough patients to De attended to there. I ravel time can be cut down dramatically while the expertise is
made available in real time via technology. The specialist's physical presence becomes necessary only when a
surgical procedure is planned. In reality even surgical procedures are being conducted with guidance from the
specialist who is at a remote location. Foi a patient cost of travel is a major worry especially if she has to fly in to a
specialist care center in a city.
Pressure to reduce costs: Cost of healthcare and questions on who will bear the burden of care are issues across

the world, developed countries included. The incidental expenses related to patient care, i.e. the cost associated
• with factors other than the actual medial care such as travel, accommodation for relatives, food etc also contribute
substantially to the cost of treatment. In a country where health insurance is yet to catch up, cost of acre is borne
by patients, in many cases by selling property and livestock. If hospitals can reduce these costs associated with
treatment it would go a long way in reducing the burden of care on the patient. Telemedicine seems to be the
answer.
AvaiSabsSity of healthcare facility/ transportation
It is no understatement if I say that healthcare deliver/ in rural India is not adequate. The government has
limitations and so does private enterprise. Setting up a full fledged care facility at a remote location might not
always be economically or operationally viable. Even it there is a healthcare facility with bare minimum resources,
transportation might he a challenge. Various studies have documented the inverse relationship between distance
and outcomes particularly in acute MI and ventricular arrhythmias. Training telemedicine is an effective medium to
impart knowledge to professionals within a healthcare organization. This becomes relevant in corporate hospitals
chains spreaa across me country wnerein they couio share ana institutionalize best practices across the group.
Telemedicine could also be utilized to provide public health education to the remote corners of India.
Teiemedicine for competitive advantage
Telemedicine is a iecin luiuyy-eilabiud iiidiketing tool as well. It makes it possible for hospitals to address the
needs of patients who might not have otherwise used their services. Slowly and steadily telemedicine is being
utilized as a tool for competitive advantage, which would over a period of time, lead to a divide in the healthcare
industry along the lines of "telemedicine haves and have nots7'.

The players: The two major players in the telemedicine space in India are Apollo Hospitals and Asia Heart
Foundation. Between the two, several remote villages have realized the benefits of technology-enabled care. The
organizations are now in a position to share the expertise available in-house with neighbouring countries too. The
missionary zeal with which these hospitals operate will ensure that distance does not deter patient care. The public
sector too is taking steps in this direction. According to Dr Alok Roy, Asia Heart Foundation, several lives were
saved by telemedicine intervention in far flung villages, which might not have been otherwise possible.
Issues: Beneath the glossy reports of telemedicine successes, there are many stories of hard work, dedication
which happen behind the scenes to make this all happen. Making Telemedicine work is not as sweet as the
reports. Some of the issues involved are outlined below:

Connectivity: Connectivity for telemedicine is a major concern as many of the remote villages do not have basic
telephony. Thus an exclusive satellite from ISRO to service healthcare needs is revolutionary and will change the
dynamics of telemedicine in India very soon. Satellites provide almost 100 per cent uptime, making it the best
medium for countries such as India with diversity in terrain. The bandwidth available with various connectivity
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As telemedicine becomes ubiquitous, a chaiienge to be addressed is adherence to standards. A few years down the
line, when corporate mergers and acquisitions become commonplace in the healthcare sector integrating to
leverage investments made be a major roadblock to integrating services. Integrating disparate systems could be
expensive in the long term, unless standards are followed from day one. HL7 and DICOM are two standards that
are critical for the success of Telemedicine in India.
Security & Privacy
Security and Privacy are no serious concern in India at the moment as consumerism in healthcare is yet to take the
proportions in thp developed world However this is set to change soon. As patients become more aware, thanks to
the Net, these concerns will have to be addressed. European and US standards for Privacy and Security are being
ii icorpoi ated by veiiduis in iiivbc cuui lil ies.

IHE

Integrating the Healthcare Enterprise initiative is a US initiative by leading trade organizations in the US. The role
• of lTe is the integration of healthcare information, promotion of existing standards (eg HL7, DICOM, CORBA, XML)
and implementation profiles for transactions used to communicate images and patient data within Hospital
Information systems Radioloav Information systems ( RIS) and Picture Archiving and communication systems (
PACS). These initiatives wii! make the move towards a Telemedicine enabled Electronic Health Record.
Legal & regulatory
Who is liable is a telemedicine assisted remote surgery ends in a disaster due to loss of connectivity? The surgeon?
The Satellite provider? The software/hardware provider? What is the legal status of a telemedicine based diagnosis
in a medico legal framework? Many of thee questions have not been raised in India as we are still in the
honeymoon phase of telemedicine, when ail news is good news.
Management issues
Strange as it may sound the major areas of concern in telemedicine implementation is not technology perse, but
the organization's preparedness to handle the management and human resources issues related to the same.
Telemedicine is a iaboui intensive process which involves co-ordination with sending and receiving stations and the
staff technical, clinical and support staff at the centers. Management buy in is slow in most organizations. Training
the doctors, nurses and technicians on a continuous basis is critical, more so as employee turn over is increasing in
the healthcare setting. The success definitely depends on the management's commitment to a long term strategy
to aciiieve competitive advantage utilizing teiemedicine.

Gr.K frn swaf up fra«sk fnrcR for telemedicine project implementation
HHM Ns’.'.'c E'_!r22— - Eangalcre

Tne Government of Karnataka is in the process of setting up a task force for implementation of telemedicine
projects in co-ordination witn an hospitals ana government machinery, Dr G Paramesnwar, state minister for Higher
Education and Medical Education. Government of Karnataka, has said. He was speaking at the inauguration of
California-based company Teievitai Inc's unique technology which empowers medical ser/ice providers to monitor,
diagnose, treat and manage theii patients from any remote location, anytime, thus overcoming the barriers of time
ana aistance.

Healthcare being one of the priorities of the state government, it is determined to provide better specialised
facilities in healthcare system to rural masses at cheaper cost, the minister said. 'Televital will play an important

role in the deliver/ of technology in healthcare. We are planning to provide this facility by networking al! the district
and taluk hospitals and all other pubic health centres in the panchayat levels. Initially we are looking at Hubli and
Dharwad," he said.
Director of Medical Education, Government of Karnataka, Dr Seethalaxmi said, "Telemedicine is already present in
a small way in the eight government hospitals in Karnataka and with Televital. we see scope for implementing
telemedicine on a larger scale."

Televital Inc was founded with the vision of empowering medical service providers with the potential life saving,
time saving ana cost saving tools ana services to monitor, diagnose, treat ana manage patients without the
harriers of time and distance It snecializes in providing a browser based integrated electronic patient care system.
Rea! time streaming can take place ever broadband networks or DSL lines, diai-up modems or 2.4K Iridium based
batciiitc phones. The acuuiicd vital data can be securely viewed using a PC or handnela device by medicai experts
who can be anywhere in the world. Multiple doctors in a conference mode can view tne same data.

Speaking on the ocrasinm Rajan K Pillay. CFO and director, Indian operations of Televital said, "The technology is
ver/ useful in a situation where it is net practical for everyone to build speciality hospitals/'
Televital has built a working relationship with NASA for their applications. It can regulate hospital application
anywhere in the world and orovide medical connectivity like pulmonary functional testino, anesthesiological
monitoring and so on. The company is also looking at providing remote training and supervision in medical schools.

"We are initially looking at healthcare organisations in the South for our technology. Telemedicine can carry total
medicai specialities like emergency healthcare, home healthcare and distance education. The technology is viabie
for a country like India which has 23,000 PHCs, district hospitals, multi speciality and super speciality hospitals with
one doctor for ever/ 15,500 persons as against one doctor for ever/ 500 persons in the developed countries.
However we need to provide error free and reliable information with user friendly medical technology to increase
diagnostic medical efficiency/' said Prof M N Shivaram vice president, India operations.
"What we need is proactive support from the centre and state governments. We are planning to go for a contract
with ISRO to provide medical education link for teaching hospitals/" he added.
Tn Tnriia

rjarojnfk/ ectahtiched a iinV f'ph^ppn Amrita Tnctitnta nf M/adirai ^Hgnrfjc a SnA-hed miiiti-

speciality hospital at Kochi with the Amrita Kripa Charitable Hospta! at a remote village called Vallikavu, a distance
’ of shout isn kms to provide rn^lir^i stwiAiity consi jit^Mon to the rural area in m*' hme. Tetevital plans to expand
its'network to Andhra Pradesh, Tamiinadu and Lakshadweep. In future Televital is looking at foraying into some of
the fuiufe segments iike home heaiihcaie. ciinicai liidis. remote care for tiavei industry and correctional laciiities.

i eiemedicine service in rune primary health centers
by V.Radhika. India Abroad News Service

Pune, May 3 - Those living in interior Pune villages will now be able to avail expert medical council well within their
means, thanks to a unique telemedicine program.
The Pune district administration has reamed up with www doctoranywhere.com and Tata Council for Community
Initiatives (TCC!) to launch a telemedicine service from a government primary healthcare center (PHC).
The service, says the Chief Executive Officer of Pune district administration V. Radha. will reduce the traveling time
and expenditure of the poor villagers.
The villagers rush to big cities to meet specialist doctors. Since their relatives often accompany the patients, the
cost mounts up. The service launched at three primary health centers is targeted at the rural masses.. Radha told
SANS.

There are 68 PHC's in Pune district, each manning five to six sub-centers. The PHC's are manned by two doctors
each and equipped with basic medical facilities, including operation theatres, laboratory and a pharmacy. The staff
consists of 15 personnel who travel to the sub-centers to implement government programs on primary health,
vaccinations, leprosy and AIDS.

The telemedicine proiect. she said, will ultimately connect al! the PHC's in the district. In the first phase, three
PHC's in Wagholi. Chakan and Paud regions would be linked with the district administration of Pune and the
e;r>fac.ioiic:T£

"if we have the headquarters connected with these PHC's. we can respond immediately. If there is an emergency,
we can at leasi rush medicines. There are ai ieasi five ro six aociors always present at rhe headquarters wno can
respond even if there are no specialists."
As part of the project, a two-day training program was conducted recently for 12 doctors. According to Chetan
Shetty of doctoranywhere.com, "These doctors along with the doctoranywhere team will train the key users of the
computer and impart training about the software provided for telemedicine at each heal

Internet is an emerging key component of telemedicine
infrastructure in developing nations
20«h July 1999
Madanmohan Rao*
World Te’empsiirinp Siinimit
Buenos Aires
fhe certified elimination of smallpox from the face of the earth in 1986 was the greatest
public health success story in the world. The second - but less well known - success story
was me use of ii ana telecommunications in the control of river blindness in West Africa
i-nt-lirf thiv

Tl involved sensors, telephone lines, satellite links and computers for the surveillance and
trackinQ of the deadlv black fly larvae living along 50.000 kilometers of the Volta river,
wllivll i’UilS tlli’G’ugll 1 1 WvSt Aliivail vOUlltHCS.

"Today, new forms of communications and information technology like the Internet are
becoming an important part of the national infrastructure for health care around the world.'’
according to Dr. Salah Mandil. health informatics director at the World Health
Organisation (WHO).

rlMiciWis
aYouKd the woVia daTfered itec^iy ift Auehos Aites, Arseiiuha, lor me
International Telecommunications Union's Second World Telemedicine Symposium for
Bevel i >ping Coun hies.
A ]VTuKi(HKcir»Iinary Approach

Around the world, costs of health care are going up - but IT and telecom costs are
dropping Governments are also under coming under increasing pressure to cut costs, make
their services more economically affordable, and privatise sectors like telecommunications
and health care.
■' 1 ho challenge in telemedicine systems is to harness now technologies and operating
models while also improving equip7 m access to high-quality health care,'1 said Mandil.

I elemedicine requires a muhidisciplinar/ approach involving varied sectors like
telecommunications. 11. medical experts, general practitioners, hospitals, equipment
suppliers, logistics companies, government agencies, social workers and universities. It
also brings to the i.abie a wkie range of technologies like radio, analog land lines, e-mail,
Internet; ISDN, satellites, and tele-sensors

Telemedicine systems harness information and communications technologies in several
wavs: for administration and management of health care systems, transferring and storing
of clinical data, surveillance during epidemics, publication and search of medical
literature, and education and training for healthcare workers, students and individual
citizens
Benefn*
Theorelicaiiv. telemedicine can provide crucial benefits and savings by reducing the time
to travel for dor-tor^ nrovidtno footer access to medical expertise (especially during
emergencies), using health caie resources more effectively, and upgrading skills and
knowledge tor medical professionals.

1 or instance, satellite links between hospitals in Mexico City and ton rural hospitals in the
Mexican province of Chiapas reportedly reduced unnecessary referrals by 60 per cent.
Cancerology resources in France were tapped from Tunisia via satellite connections. Emaii is used heavily by health care researchers ax rhe University of Lusaka in Zambia.

A conference on Alzheimer's disease in Argentina greatly benefited from participation via
the InTerneL Many cases have been documented on the use of The Net to save lives of
patients in countries ranging from China to Turkey.

Medical Literature and Data
Though the Web is not yet well suited for the kind of broadband realtime communications
that videoconferencing for remote diagnosis sometimes calls for. it is superbly geared
towards the publishing and search of health care literature as well as transmission and
acrchival of image data.

"The function of information sharing, now expanding in developing countries via Internet
access, may be the most valauable of all telemedicine applications,” said Heather Hudson,
author of “Global Connections: International Telecommunications Infrastructure and
Policy" and a coordinator at the International Develpment Research Centre (IDRC) of
Canada.
Tn chfIv
the C^diicr-iK rrniect was launched in Peru for the establishing a biomedical
iiifoniidtiOii sysiciii ill Spanish oil tlic Internet.
Computer networks are now used to coordinate health monitoring of 700.000 victims of
the Chernobyl disaster in Ukraine. Web-based telemedicine projects have been launched

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There are also gateways to online medical resources of Europe such as EuroTransplant, to
coordinaie services for organ, tissue and ceil Transplants. Medical universities and research
institutes are linked via a three-tier network called 'UkrMedNet."
’’The Net has helped accelerate the intergation of our medical system into the world
informational space.” said Dr Oleg Mayorov, chief medical informatics advisor at the
Ukrainian minsitry of health care.

Online academic literature and tele-education systems are becoming an important
component of the medical education system and national health infostructure. The growing

muscle of the Net can also be evinced from the vast array of resources available from sites
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Though full connectivity to Web-based databases may be a long way off for the medical
sector m many developing countries, email messaging lists and email-based database
gateways can come lo the rescue here.
"For example, reliable email services via the Internet have been introduced and used in
parts of the health sector of at least 38 of Africa's 49 countries,” according io Dr. Mandi! of
WHO. Over 80 per cent of telemedicine traffic in the world is over store-and- forward
messaging networks, he said.
One of the best success stories ofcmail-based medical support comes from SatelLife. This
Massachusetts-based non-commercial organisation provides free store-and-forward
messaging services for developing countries via a low earth orbiting (LEO) satellite called
HealthSa1>2.

The HealthNet email service (v.w.v.healthnet.org) provides literature summaries, expert
commentary, event information, and community discussion facilities in numerous fora like
the cardiox ascular health foram ProCOP.. wliich has participation from health
professionals in 51 countries.

The TTeahh'NTet network has ako been used by bum surgeons in Mozambique, Tanzania
and Uganda to consult with one another on surgery techniques.
The Tntir. American Healthcare Link programme provides email-based discussion and
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The growing importance of telemedicine was formally recognised during summits like the
First World Telemedicine Symposium tor Developing Countries, held m Portugal in 1997
by the ITU. The ITU and WHO have formed study groups around the issue, and also
conduct pilot projects in partnership with private sector players. The ITU published the
’•Report on Telemedicine and Developing Countries" last year.
The Midjan Group, pail of the European Health Telematics Observatory (www.ehto.be),
provides European telemedicine services to developing countries like South Africa and
Senegal. The Observatory has five national language affiliated sites in Fiance. Portugal,
Spain. Greece and Finland.

Satellite consortia like Intelsat and Inmarsat have been involved in numerous telemedicine
projects. Other telecom and datacom projects to watch for include AT&T’s Africa ONE
project and Project Oxygen. WorldSpace has three three geo-staitonary satellites AsiaStar,

mn ar ana v art etaiar tor uigiiai auaio oroaocasumg in aeveiopmg coumhes

Inieniational NGOs like the Association for Progressive Communcialions (www.apc.org)
aiso provide low cosi. Iniemel solutions for non-commerciai use in dozens of developing
conntries TDPCs Acacia project (ww'w.idrc.ca/acacia) specialises on providing such
IlliCiiiCi i’vSOui’CCS tv

wuiiiiiCS.

Till 1995. most telemedicine projects involved cooperation between developed and
developing countries, but the Net has helped more South-South collaboration between
developing countries in recent years.

Project Challenges
Many telemedicine pilot projects have been launched around the world, but several have
faced challenges in areas like measuring the clinical and cost efficacy of telemedmce, and
in devising norms and standards for (he tools, languages and quality control mechanisms
used
Formats for the reportage and documentation of telemedicine experiments and
mechanisms for puaranteeinv securitv of patient data are other kev concerns. Tn addition to
inti asiiuctuic shortages in developing countries, there have been several project
assessment challenges as well.

An ambitious teleradiology experiment using imaging equipment and special Telecursors"
for interactive diagram aiscussion was launched by Mauritius l eiecom.

But there were was no clearly defined mechanism tor evaluating the project, and the
equipment was not adequate!'/ used by the intended audience, said R. Seenundun, technical
head for tetiniinrJ cervices MHmirins Telecom.
"For effective telemedicine, IT use in hospitals should be increased to improve computer
literacy. Telemedicine, svsterns should be integrated into the traidttonal working
environment. Adequate training should be provided, and key personnel should be trained,"
he said.

South Korea launched major telemedicine projects for local medical care centres in
farming and fishing villages with satellite and Internet links to the Seoul National
University/ Hospital and Korea University Hospital.
’’But such services were not covered by the medical insurance system. There was also lack
of clarity on how doctors and hospitals were io charge for such sendees,” said Sung-Ok
Tec. informatics director at the Korean ministry of communication.

A triiv nf Internet and Inft rniFt delivery is Used by Argentina's APGONAUTA service
(hup. tin.tm.coiiae.gov.ar) for tele-radiology from hospitals in the city of Cordoba.
According to designers of the project, challenges arise in standardisation of medical care
protocols, especially with regard to integration with inter-regional or global systems.

Legal. Cultural and Political Issues
1 hough Web based access to medical literature has skyrocketed, many exports wain that
literature published on the Web needs to be carefullv checked for authenticitv, credibility
Telemedicine is meant to augment - and not replace - traditional practices and channels of
medicine, but se\ era! doctors tend to feel threatened by such new technology-based
approaches Legal iiabiiiiy issues, especially for trans-border commiinicalions, are not
easily sdesolved

Affordable access to quality health care is a fundamental human right, but care needs to be
taken to bridge the growing “digital divide" between urban and rural areas, developed and
developing countries, and English and non-English speaking nations.

Sustainability of telemedicine projects = many of which do not go beyond a pilot project
stage - is a key concern, and care needs to be taken to ensure private sector participation in
ciirh iceiipc
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A growth industry is booming around telemedicine technologies and sendees. For
instance, the vision iecnnoiogy Group in Bogota, Colombia, uses the internet, satellite
ar'd
cnnn.-nrp fr>r taiA-mrtiniogy ^ep/icesj it plans to extend its offerings to other
Luim Aiiiciiuan CQUiiliics.

Many countries are thus in a position to convert their telernedicine expertise into an export
earning, but challenges also arise in regulating and monitoring cross-border trade in such
practices.

Telemedicine in Asia
The Interactive Medical Curriculum Project (vAVVv.hol.com.aiPcurriculumkindex.html) is a
major APEC (Asia Pacific Economic Cooperation) project for online tele-education
cooperation in medicine.
Medical schools in Indonesia, Malaysia, Papua New Guinea, China, Japan, Philippines,
Thailand, South Korea and the U.S. are collaborating in this initiative for electronic
delivery of interactive medical curricula, according to project manager Anne McLennan.

The HealthNet email service has been available in Nepal since 1995. For a country with
scarce medical expertise and uneven distribution of population l ike Nepal, it is more
appropriate io concentrate on simple telemedicine solutions involving low-cost PCs and
basic text-based email , said Dileep Agrawal, CEO of the TSP Worldlink Communications
in Kathmandu.
His company is working on providing PCs to hospitals, training health professionals on the
use of Internet email, and create email discussion lists for consultations.

Multipurpose communnv telecentres are being launched in Bhutan by an initiative of the
al Medical Centre <?f Bosion, wilh funding from international donors.

In India, telemedicine projects will be implemented next year by the Department of
Teiecommnnica’iens, according to P.K. A_garwal of the Telecom Engineering Centre in
New Delhi.
Numerous first-generation Web sites focusing on ayurceda and homeopathy have been
launched by Indian entrepreneurs, but Internet-based telemedicine is still at the embryonic
stage m India.
One of the best examples of telemedicine in Asia comes from Jordan. In 1997, telecom
engineers, heart specialists and two major hospitals founded the teleradiologv service
HeartBeat Jordan to help reduce the "symptom to needle time” for treating partients of
hean problems, which accounied for 45 per cent of the country s mortality rate

Heart specialists in Amman receive and diagnose ECG data via satellite, land lines and the
Internet from medical centres, corporations, hotels, holiday resorts and even the Royal
Jordanian Airlines

Pilot tests have shown that the service can cut down unnecessary referrals and provide
better service in many situations, and the company is even becoming profitable this year,
according to Dr. Khalil Zayadin of Heartbeat Jordan.

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The service is being extended via the Net to other Gulf countries:
inquiries are also coming from European countries like Germany.
Untortunateiv, there is not enough support and recognition coming
for the project from health ministry officials.

"The public heahh sectors in many developing countries have limited resources and even
more limited vision. Information and communications technologies tend to be dismisssed
as expensive — but a well-developed solution using these technologies is sometimes the

only economically viable solution.” said Zayadin.

India: F@!@meuicing’s Groat New Frontier
An indiqenous technology effort is wiring up its healthcare system
Rif 5^1 Ilf Worries

>orrprar»/ _ !ntf»rnaririn2M ^nriorv for TpJerrieniCfnf?

Champions of telcmcdiGii’ie, the systamatic application of information and telecommunications technology to the
pracnce of neaimcare nave oeen very paneni. By me i9ous piior projecis oegun amio great nopes in me i950s
and 1960s had fizzled out for the most part. More recently, however, telemedicine has undergone something of a
irgenef:
terhnnlociy
hegiin catching un with aspirations Perhaps nowhere is this renaissance SO vitally
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With their dependence on high-bandwidth real-time technologies, most telemedicine projects of the past decade
nave oeen m suirea to inoia now. rnougn, new nones are being engendered mere ny rhe confluence of iowbandwidth telemedicine with a orowino middle class, an improving telecommunications infrastructure, a world-class
software industry, and medical community open to new ideas.
The facts or. India's healthcare situation are sobering. With a ratio of one hospital bed for every 1333 citizens, the
huge country <s fur behind even the Pi iiiippines, at 1:600, Set alone the United States' 1:212. To get to a more
reasonable 1:500 ratio would require me annual construction of 700 new 2h0-bea nospirals for years to come.

India has one doctor for every 15 500 people. But most doctors live in cities, whereas 70 percent of the
subcontinent's population of just over 1 billion lives in rural areas.
Figures on the percentage covered by health insurance vary from 3 to 9 percent. For the hundreds of millions of
poor Indians, healthcare is nominaiiy a government responsibility. Bui spending on rreaiiheare represents oniy 0.9
percent of gross domestic product, as against around 14 percent in the United States.

The basic unit of the public system is the Public Health Center, which is typically staffed by one or two general
practitioners and 10 or so nurses. Each of the centers has a few beds for simple in-patient procedures and perhaps
X-ray arid lab facilities. There are only about 23 300 of these for some 600 000 villages. Above them in the
heaimcaie niefarciiy are cisuici nuspiiais and, in a few cities, muitispeciaiisi hospitals. To get care, those who can
afford it tvoicallv spend days traveling.
Anothpr cornnlipating factor that India's gcTvarnment-rijn healthcare system must coexist with hosoitals run
bypubiic end private trusts and with cn active private sector, which caters to middle- and upper-class Indians and
Ccif i p'ey salai les aipui id ■ 0 tiules itie public > ate. Even the most prominent private group. Apollo Hospitals,
manages oniy aooui ^uuu oeas mrougnoui me counrry. Tnere is no aouoi mat couniiess men women ano
children could al! benefit enormously from telemedicine.

Fechnicai ministries take the iead
Two government institutions are leading the way One is the Indian Space Research Organisation (ISRO). The
other is the Ministry of information Technology, which already has 200 sites used for telemedicine and other
purposes. The sites arc linked by 123-kb/s integrated-services digital networks (ISDNs) or by satellite and offer
occasional videoconferencing for medicai ieieconsuitaiion and education.

The Ministry of Information Technoloqy's National Informatics Center plans this month to bring on-line a 384-kb/s
ISDN linkina three teachina institutions, the Saniav Gandhi Post Graduate Institute of Medical Sciences in

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impoverished state with teloconcultation and education programs. The agency is also launching telemedicine
projects hi Seveicii otllei aicao that liavc mccii pailiCuiarly uiiderserved by healthcare piofessiUiiais. the Andaman
a Nicobar isianas, rar to me east of moia in me bay or Bengal; LaKhsndeep isiana, oft me southwest coast; and the
Leh Mountain areas in the Himalaya range in the state of Jammu and Kashmir.

ISP.*?’ has also provided access to its V-SAT (very small-aperture antenna) communications infrastructure. Apollo
Hospitals' new. small hospital, based in the village of Aragonda, is one V SAT user. The 10-bed hospital was newly
buiilaiid equipped with inudein uornputer tomuyiaphy. ultrasound, echocardiography, automated laboratory
equipment, incuoators. and electrocardiogram equipment. A pediatrician and a general surgeon were madeavailable in addition to Generalists. Using both store-and-forward and real-time technologies such as
videortoriferencing, some 200 teleconsults have been provided to this village alone from specialists in Chennai,
formerly Madras. Data is managed through a locally developed software package. Mediscope.
This iast indicates a characteristic of iridian telemedicine—it is a largely indigenous affair. India's prodigious gift for
information technology has produced world-leading software and systems, obviating the need for expensive
imports. The range of svstems developed is already wide, among them assorted mobile vans equipped with basic
pjafienf monitoring (likp pIpcTrocs’rctingrpph^) and short-range wireless communications equipment. It might even
serve as the basis for an expert industry', particularly to other countries with limited IT infrastructures.

Si!Cce‘SSi?‘5 on s latrc’4? scs!1?
Can Lclciiicdiuli io fcdily inake a diiTciericc in inula? Two recent events suggest it can. The Guiurat earthquake on
27 January zuu'i oevasraTea me western city or Bnuj and iert mousanos ceao ana many more nomeiess vvimin 24
hours the Online Telemedicine Research Institute (OTRI) in Ahrnedabad. about 300 km from Bhui. had established
telephone links- between en emernenev command center in neinhhnrinc GhandhlnecAr and various
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in one monii i. the hookup uansmiiLed io specialists in Ahrnedabad approximately 750 sessions involving primarily
A-rays and eiectrocaraiograpns or patients in tne disaster area. After two days, me satellite pnones gave way to me
more economical V-SAT (which requires a 2-meter dish), with phone lines and ISDN being added as infrastructure
r?sppirf=d Mi irh of thp imaging ^nri
frpncfAr was mediated bw PAnrii im 3-hased PCs Fvenfualiv
engineers established a full-fledged telemedicine system supplying teleconsultation in pathology, radiology, and
cardiology over ISDN linos between district iiospitais near Bhui and others in Ahrnedabad.

I he second encouraging project was carried out during the Kumbh Mela, a Hindu festival held every 12 years that
last year drew 25 million pilgrims to the banks of the Ganges River. Here, the OTRI and the Saniay Gandhi Post
‘Graduate insrifijfp psrahli^hpd a stanon under the sponsorship of the Ministry of information Technology to monitor
levels of cholera-causing bacteria in the river 'water. Microscope images of samples of microorganisms from the
river were transmitted to the institute's experts in pathology and microbiology for identification and analysis. In
addition, radiology and cardiology data was transferred to specialists for the total or 202 pilgrims who fell ill. The
project ran for 45 days.

interestingly, it is the engineers and technologists, not physicians, who have pushed hardest for telemedicine. "The
Ministry of Health has not started any activity, not even R&D," noted professor Saroj Mishra, head of Endocrine
Surgery at irie Sarijay Gariurii rust Graduate irisiituie.
Pathologists have been something of an exception. Just this past December, the Indian Association of Pathologists
and Microbiologists organized a symposium on telepathology at their annual conference in Mumbai (formerly
Bombay). Among other topics, the more than 500 participants heard a formai announcement of the establishment

of a tree consultancy, at telepatholoqymdia.com, providing second opinions on diagnoses from a range of Indian
and international exnerts
A. number of other det coms are in the game, including DoctorAnyw'here.com, a Web-based service through which
iTiOi'e than 1000 physicians in private practice now consult with specialists. In April of iast year the service was
offered to me puoiic neairn system st no cost, oeginnmg with a pilot program ar a Pubiic Health Center in Wagholi.
near Pune, in collaboration with the lata Council for Community Initiatives, the humanitarian arm of the country’s
largest Indi istrial group

Perhaps the greatest lesson of India’s recent telemedicine experiences, and one applicable to any developing

/cQUhtryi is that a lackoi physical infrastructuhlr no longer precludes the deyelopment of an effective healthcare
sysiem Tne v'vesrs resource-intensive speciany-care institutions, tne cornerstone of inoustriai Age medicine, are to
a large extent obviated in the Information Age by telemedicine. India can be the template for a new kind of
healthcare.

Acknowledgments: f he author wishes to thank Milind Purandare. Zakiuddin Ahmed, Srikrishna Sharma. Ragesh
Shah. Leonid Androuchko. Saniav P. Sood. Sunil Kumar. M.K. Baruah. and Saroi Mishra for their advice and
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Banaalore: Karnataka Chief Mi n i s t e r. s
M
K r i sh n a o n
A n r i I A i n e u n u r a t e d t h A ! A I - m e d I c i n e 0 r o i e c. t in
i n t h e state
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n a r a y a n a
h r u c a y a ! a y a
a s r h e h u n to c e a i W i tn coronary
as
heart p r o b I e m s .
lakh telemedicine project links
a m a r a i n a 9 a
d i a i r i c t n o s p i t a I a n d V i v k a n and a
ivi e m o r i a i nos p i t a i . a non-govern
m e n t o r g a n i sa t i o n
no
h e a 11 h u nit. i n H D
K o t e t a I u k.
11

run

The project inaugurated
o n April 8 i s the fourth such
telemedicine project linking remote
r e mote or distant areas w i t h
s p e c i a i i s e d doctors at well-equipped h
i o s p i t a. i s located i n
cities.
The first project 'W 2 S u n d ertaken w i t h two v i i I a g e s i n
Andhra P r a d e s h ,. vV h i ch
w ere linked a large hospital in
C n e n n a i
The second linked Anda man and Nicobar I s I a n d s w i t h a
s p e c i a ! t y heart centre,
c e n ire, w h i I e another heart c e n t r e a t
U d a y a p m r n e r Agartala i n T r i p u r a i s connected w i t h
R a vinoranatn
i a g o r e H
n <e art S p eciaiiry
ci a 11 r y Cenrre i n
K o i k a t a
and
Narayans
H r u d a ya I a y a I n Bangalore.

K a r- r 2 t 2 k

project ! S 2 shot in t h e 2 r
t o treat p a t i e n t s i n r e m o t e
a f e a s and is c o n s i d e r e u
a
rn a j o r step ti o r w a i d i n I ri e Fig h t
against heart disease. w h ! c h a large part of t h e
Indian
n o o u I a f i o n i s p rone i o s u f f e r fro m .
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TELEi’iEOiCIHE IH IimuIA1

■ HE APOLLO EXPEPIEHCc:

-3a.v

Dr. K Ganapathy.
Meurosurgecn, £ Mcd’cc! Director, Apoiio Tejemedicsne, Apoiio Hospitals, Chennai, India.

" Watson, come here I want vou" said Alexander Graham Bel! on March 20,1876, when he inadvertently spilled batter
acid on himself, while making the world's first telephone call. Little did Bei! realize that this was indeed the world's firsi
telcmedical consultation. Wc have come a long way since then. Today even tele surgery is a reality. This article will br
review some aspects of Teiemenicine particularly its relevance in a oeveioping country like India and the experience ol
AdoIIo Hospitals in setting up telemedicine centers.

Introdi’ct'en:
Secondary and tertiary medical expertise is not available in several areas of the world. Quite often, many patients are
eisewnere at considerable expense, m a number or these cases the treatment could nave been carried out by the ioca
dnrrnr- with advice from a snerialkt Fvan within a country there is a tendency for snerialists to concentrate in the big
making medical care in suburban and rural areas sub optimal Using a PC, a scanner, a digital camera networking,
dppiopiidie sui'iwdie diiu leiecumiiiuiiicduuiis it wiii be possible io ildiisiei cimicdi Udid floiu any part of the WOiid to <
other part.

Offarinn m^diral sdvi^ r^rnoMv ucinn stat* nf th* art tHl*rO»Yimiinication took is HOW s
- Rjiihr fpahite in several pa
the world. Several studies have shown tdemedsemo to be practical, safe ar.M cos., c-.e.ictive.. Telemedicine hinges on
geogiaphicaiiy
separated locations Success reiaies to the
udiisfei of texL lepons. voice, images ano video, between g
.
efficiency and effectiveness of the transfer of information

(

Tcleincdiciric is a method, bv which patients can be examined, investigated, monitored and treated, with the patient a
me doctor locatea in aiirerenr places, leie is a Greek word meaning "distance "ana *ieden is a Latin word meaning, J
heal" Time magazine railed Telemedicine "healing by wire". Though initially considered "futuris.ic anu expen.nemai
Telemedicine is tedo e reality end has come to stay. In Telemedicine one transfers the expertise, net the patient.
Hospitabof the future wiii diain udtients from ail over the worid without geographical limitations^In Cybena a^r all c
a netizen! Hiqh quality medical services can oe Brought to the patient, rather than transporting the patient to djsanit_e
Pensive iptfiarv rar? rPntrw A maior noal of telemedicine is to eliminate unnecessary rravel.mg
pa,,™,.., «« ihet
escorts, image acquisition, image storage, .mage display and processing, and image transrer represent the basis or
telemedicine. Teiemedicine is becoming an integral part of health care services in several countries including die UK, I

Canada, Italy, Germany, Japan, Greece, and Norway and now in India.

<A.hat u xh-

in a developing country Id-e India and particularly in the specialiti

of

The following tabie indicates the ground realities of the present state of health care in India,

million live in rural ,r>uin

f Pf-)

Bed-Popuiatiun ratio 1.1333 (1991) Vb. idea/ of 1:500

2 million beds are reouired as aoainstO.7 million available.
700 hospitals of 250 beds each are required every year,

only 9% of 1 bilfion people are covered health schemes,

only 0.9% of GDP for health (WHO recommends 5°4j)
nf annual fnmily inmrna spent towards curative health C^r<=-.
Hill I

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In Utopia, ever/ citizen has immediate access to the appropriate specialist for medical consultation. In the real world t
cannot even be a dream. It is a fact of life that" All Men are equal, but some are more equal than others We are at
present, unable to provide even total pnman/ medical care in the rural areas, secondan/ ana tertian/ medical care is n<
uniformly available pven in suhurhan ano urban areas. Incentives to entica specialists to practice in suburban areas ha
failed. After ail professional isolation would lead to mediocrity, which is one step away from entering the Jurassic Park
ncaiti i foi Aii may be a biuyaii even in 2020.

It is aenerallv considered that communities most likely to benefit from telemedicine are those least likely to afford it oj
uAVp thp rpHiikitp romrriiinir^tinn infrsctn jcti ire

This may r.o longer he true. In contrast to the bleak scenario in health care, computer literacy is fast developing. Pria
are failing, r-ieaiin care providers are now iooking at Telemedicine as rheir newiy found Avathar. Theoretically, it is far
easier to set uo an excellent telecommunication infrastructure in suburban and rural India than to dace hundreds of
medical specialists In these ^iaces. We have realised that the future of telecommunications ”es 'n sateB’t^-based
qi ivi huci
iil/ci OptiC
upiiv C
tGuico.
riuviuinq
tcCiiilOiOqy aiiu
cjOicjo. PiOViuifiM
health Cafe ifi ici'iiOte aieaS using hi tech is not as absurd as it may initia

appear. Couid even the greatest optimist, have anticipated the phenomenal explosion in the use of computers, in Indi*

What does teSemedksne encompass?
lelemediane covers a wide range of activities. In the past it was primarily teleradiology - the transferring of
resolution medical imaoes, X ray pictures, ultrasound, CT, MR! pictures, live transmission of ECGs and echocardiog
Today even a detailed clinical examination can be conducted remotely.
What are iric auvaniaues of ioiemouicine?

Worldwide there is difficulty in retainina specialists in non-urban areas. The distribution of specialists in India is ir
Inncidf^d

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luyCnid. wniniiuiiy uCi uiv»iy Caic hospikuiS sic also concentrated in pockets vviuii iaigc segments of the population havii

access, i he increasing avanaoiiiry or excellent telecommunications, infrastructure ano video conferencing enuipmer
help provide a physician where there was none before.
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save lives. Once the "virtual presence" of the specialist is acknowledged, a patient can access resources in a te
rererrai centre wiinom: me constramis or disrance. ieiemedicine aiicws parienis io stay at nome ensuring much n*
family support. Tn a large Telemedicine project in the USA 83% of patients who would have been transferred to an
hospital remained in their community reducing the cost by at least 40 to 50%. This also ensures maximal utiiisati
suburban hospitals. Tne general practitioner in the rural/suburban area often feels that he would loose his patient t
city consultant, with ieiemedicine tne community doctor continues to primarily treat tne patient under a spec!
umbrella. With modern software/ hardware at either end 90% of the normal interaction can be accomplished thi
Telemedicine.

i he following tables give some important facts which 'nave to be considered when introducing ieiemedicine in India.
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International grand rounds, Web casting conferences,
Motivstlon for cornDuter Ht^racv amonc doctors
rr-> > »H*
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useiui in designing credits fur re certification of doctors.

w!!! raster Transmission or oerrer image duality after diagnosis or ueatment f
Cnr,rdin^trtrs fzr r^rh srv^iaitv tn iay ground
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With software, hardware, brain ware and a targe number of doctors

■•censed to oractice abroad. India could offer oioba! Teleconsuitation
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MarQfna! prorits ror leieconsuitation in the metros.
TM fnr Knhnrhsin ^r.ri rnrai Tndis heavilv ^nr.sidk/^H fmm anancies Hir^ Wf-iCi Wnrirl Rank Asian navalnnmant Rank G
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limitations nf Tninrnns: iltatlnn

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/'vS in several disciplines, the Apcilc Hospitals have been the pioneers in putting up the first modern secondary care
i iuspitdi ubinu Teiei i icdidi it: Lu piuvide expert care. As a pilot pi eject a secondary level hospital was set up in a \
called Aragonda 16km from Chitoor (population 5000). This 40 bedded hospital was equipped with a CT scan, a m*
li'trasnijnd. FCHO ^ist.-rr^tpd i^Mr^rory equipment, an incubator, automated ECG etc. A paediatrician, a genera! phy
and a general surgeon were available in addition to genera! duty doctors.
Starting from simpip weo cameras and ISDN telephone lines today tne village hospital has a state of the art
conferencina svstem and a VSAT fVen/ Small Aoerture Terminal) satellite installed bv ISRO (Indian Space Res
Oroanisat’onV Abo'jt 200 tele consultations have been given to this village alone from specialists and super specialists
Chci'ii"lui. A specially designed seftTvOic (Mcdiscope) vvas used and the clinical history and physical findings uansi
from Aragonoa . images or x. rays ano uitrasouno were scanned; compressed ano senr rnro ISDN lines (64 x6 384j‘
CT imaoes beino DTCOM comnatihle were directly electronically transferred to the telemedicine computer for or
rrancmi<-cir»n tq Chenn?.!. Most of the teleconsultstjons were initia’Jw off line — store end forward. The tele consul
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avananie ar rne leiemeasane unit ar cnenna! rrem yam in spm. Arrangemenrs are now neing made io provide emen
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arnica! "examination" or pseudo seizures, involuntary movements, Parxinsonism, myopatny etc. was possioie. Soc
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In aimcct aif cases the tele consultant was abie to give a definite opinion and guide the iocai physician. Several s<
head iiiiuiica iivl icmuiiimm auiyciy wcic

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interactino with a patient. Detailed evaluation of the socio economic benefits needs to be done.
■■ r3w*«’x«w--3
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rnennas. ir is actually an island, adoui

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Expansion Plans:
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orner countnes. 1 .onnecriviry wirn rne Apoiio nospirais ar Coiomoo. unara. niiaspurr. rrone and others are on the anvii

The Tcicmcdicinc deportment of the Apollo hospitals wes the only unit from Asio which took part in the 1st
iniciiiauunai uumciciicc uu i ciemcuiuii ic in jaiiudiy 20Gi. Suuscuuei iuv a papci wds picsci ilcd nuiTi Ciiennai.
international conference on teiemeoicine at upsaaia Sweden in June 2001. ! ms was an intsrcogitlnea^! Live mult
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ah f-\Ggusi «.wl ihv» isCpi Gi 1 wx^uroGUigeny AgoliG dospivals v.hcnnai h«M a ovo hour i^iCtMonforcnvC With the Dept Oi
Neurosurgery rujirna neaim university. Nagoya japan, inis international grana rouna went of wimoura hitch, kegular
conferences such as this are olanned to be conducted oeriodlcallv.

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telemedicine is leoion. Telemedicine today sounds hep and cool, but the reality may be quite different. ;he future ho’
Piomiscs tc be c^itiny. 3c Icdivi end ycr.tlcmcr. hang an far the ride! Tele medicine wiii be mare than a roller coasts
i ne journey win wen pe worm me wair
Time alone will tell whether Telemedicine, is a "forward step in a hackward direction" or to paraphrase Neil Armstrong
small ste^ for IT hot one giant leap for Healthcare".
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Issues o! 1 ele-Medicine Practice
Tn the aftermath of the rnntinverv- snrremnding the treatment movided hv Anollo
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; who arc t-ynig to osc the developments ol Litorniation Technology to improve the
: standards or medical service would also have to watch their bacKs, lest rnev may be
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already msiiruied a sysicm w■• hereby diagnostic reports and patient records are
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meaical personnel involved, there is a danger of these people being victimiseo bv
either n rdnefni o* e firn in nilv mien tinned hneherc vrrho ro-n irirerrer\t qnd nitei* the

cnucai inionHaiioii mai mav be iioaiiiig aroUlicj.

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that the patient s records in the hospital database is tampered with to mislead the
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communication and storage of information besides the norma! risks of technology
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assistance to the medical cumin unity in this regard to the extent feasible.

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accountability ot me medical professionals nas been brought into sharp locus ihis
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luugcmvuis win lurinei acueinuaie as die Medical insuraiivt Industry develops in
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xucdical practice.

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hi the lirht of this general trend, progressive Medical Practitioners and Hospitals
who are tr;mg to use the developments of Information Technology to improve the
standards or medicai service would also have to warch fneir backs iesr fnev may be
let down bv the technolbiw. A nolle, is one institution which is ienofted tr, have
tu£vad\ instituted a svstciu wlivrcby diagnostic reports -and patient iccords are
transmitted over a nwtwork and shared bv experts. Internationally there has been
reports of critical m
medical advice being sought by medical practitioners from experts
Through rhe inTerner even while a patient is being operaTed upon in a surgical unir
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WTile such initiatives are welcome in the larger interest of the communiy . it is
extrcmclv miportant iOxi the medxcal community to rcahsc that there are ’’Security
issues" thev should be concerned with and the consequential legal liabilities.

Vf r.ila the liability for "YTrong” or ’’Inefficient advice" may be attributed to the
medicai personnel involved, mere is a danger ot mese people being vicrimised bv
either a nlavful or cnnunall" ihtent»oned hackers who can mterrent and alter the
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drug iLstii wiiiit dir donors prrscnption is bruig transmit led on dir nri. Or Iris sa\
• that the patient’s records in the hospital database is tampered with to mislead the
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: appropriate mcnisrrv rora adoress this issue and develop norms which may later be
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issues in Modern Medical Fractices ’. Naavi.com would he happy to provide
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1 he disiance between me patient ana me doctor has just been removed. With the
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irnUnr - <?•«>.•<riel» A*i<?hrM

With 80% nf Innin's ponnlntinn living in rural areas and 80% of the medical community

living in viiica. liicic is an inibaiaiiuc ni iiCciiili L-aic iCaCiiilig people. SO iiiuvii tiiai ill iiic

new millennium . 11% of the world's population (residing in our rural areas) remain
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The answer? i eleinedicine from Apollo

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when oom are miles apart from each other, feiemedicine allows medical treatment using
r-Aintniifti. Mthv, ix-Tv. -.i Vv Py n^ino r-ntrii-qiTfsuQtrii’tKinn nf -riiirno
visual data. Apollo can now dclivci uuaiiiy health care, instantly and ciftciively.
Allowing easy consulting, diagnosis, treatment and continuing education, too. Ensuring
thai a iivailbcat ill a owiudvd village vail be llCafd clearly. CVCii ill a buSy City . Thio COSt-

eitective solution has already attracted the interest ot several developing countries, lhe
/iragonda model will soon extend across 5 Indian states, covering 10 districts and 20
village groups m eacn state. Alter wnich Apoiio feiemedicine will cover the whole of
Tnni-i gitvyil'-ir ■c^wir'Ac 55-ill hf* aunh'div rv)\Fprpn hv AnoHo T-tr^ci^iif 1<? ni.’Arc:Af*q riohf hc-av

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u wiii uneuiiv eater to inc people 01 Aragoiida. and 6 neigifooring villages, nrinyiiiy

advanced, yet affordable health care to over 50.000 people.
The Ai agoiida project is n eh-equipped to support a global -quality Telemedicine
centre. comnrisinff:>

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I cicmcdiciiic Technology - CTCOM view er, direct medical equipment
interphases, health care messaging systems, scanners, digital camera, video
frame grabber, video conferencing facilities, integrated softw are for
electronic medical records, rvs and modems etc.-=
Telemedicine ser^dees referml g4>»’vinpc?* s^'^nd rktr'’,r,’nr*
iniernteiaiitni service, iieaiiii education

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Health insurance - the gram Panchayat propagates a scheme at Re.1 per day
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to Rs. 15.000 in patient care is covered, the Anollo group wil! absorb extra
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Apoiio mission has always been to bring world class health care within the reach of
every individual. A step closer towards that mission will be the launch of the
telemedicine Unit in Araytnida.
June 13,1999

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Health: Telemedicine catches up in

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Gujarat

Anosh Malekar

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fev; months ago the doctors at the Rajkot Cr> il
Hospital ’referred’ an emergency case to The U.N.
Mehta Institute of Cardiolog}' and Research Centre,
Ajimeoapad. bin the pauem dia not nave to go to

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The P^iVni Hr-..-iru'v remir»ed the patient’s rCG ifSiiio an HvenT Pecoi’de\ h

sniail cicK-uuiiic. cuiHpiiiciii resembling a iV remote control. It can record
live the FCG data within a minute and transmit it over the telephone.
Simultaneously, videos of the patient's condition were taken by a tiny
camera and the doctors’ comments recorded bv a microphone attached to a
computer Then they dialled the telephone number of a transmitting centre
whicn passea on me data to rhe specialists in Ahmedabad. fhe speciaiisrs
analysed he ECG, vie" ed ‘he paiienl.on video, heurd ‘.he P_ajko‘ doctors'
coininciils. <ind jotted down then advice on an electronic pad. which was
transmitted hack to Paikot All this in a matter of minutes And on

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leiemeaicme Research institute (O1K1), Ahmedabaa. which has
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mrougn saieiijies.. said Shan., a bioiechnoiogisi who iecj fne v ;TRI team s
dersdp-lnno rpsenrrh -.nd de^/elnnmern eff’-its in trlomedicinf1
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Hsing indigenous technology, the team developed the system with expert
advivv kvm a panel of vmment physicians and surgeons from India and
abroad. It can be used to transmit online ECG. ( 1 scans, magnetic
resonance imaging. Catldab reports, pathological reports, doctors’
prescriptions, n’pea ana even handwrinen notes, ana moving images.
Shah said that moving images, which may include X-rays, sonogiaphy.
^ngingrnnhy. ?-D echo and colour Doppler, are important in finding minor
cluvs for precise diagnosis. They enable the specialists to gather maximum
information from the patients and doctors on the periphery, during the
very first oonsultatiorf The specialists can even get a feel of the patient’s
heartbeat through an electronic stethoscope which could be attached to the
CQpit-xiiT/ar nt tn.- nprinliAral n^qltb 0011110.

Ttm rhe most imnort^nt irinnvatinn. according to Shah, is the Ttvent
Recorder (EK./. The ER lias no cords aUached io it. fire patient simply has
to place it on his chest, push a button and wait for a minute for recording
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place the equipment on the mouthpiece as per directions mven. and press

the same bimon again. The ER. converts the electronic signals into audio
signals which again get convened into electronic signals on the doctor's
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The FT was tested on domestic flights, in moving vehicles, offices and
parks. It vvofkvd to the satisfaction of medical experts.
Having successfully demonstrated the Online Telemedicine system at the
civil hospitals in Ahmeoaoad. Rajkot and <3andhinagar. Shah has now had
it installed in 58 cities and towns in Gujarat. Similar systems have been
liisuiiiud fui use m riomucopamv and ayurveda.

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i eiememcine in India

Ssnisv P. Soog

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maximum terno. touching 50 degree Celsius and in some northern regions mercury stays settled
C^kiiic fnimd thp y^’;, nopjifatinn (1 HOQ hillinn> r-i’ l.in'i infant rnrjrtaliiw

st r-waloiAf -?n

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China’s 69.76 years f31 (keeping in mind that India spends 5.2% of its GDP on health as against
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leap tire most uui of ieiemeuicine.

The Ministry of Communications and Information Technology. Government of India, has classified
’Telemedicine” as one of the thrust areas for development in the country. In sync with the policy,
the Goveiiinrciit initiated a project cailed ”Development of Telemedicine Technology”. Hence, the
acriviries in i eiemeaicine, ar Centre ror tiecrronics Design
i ecnnoiogy or India ran ISO mijo?
certified institute under Department of Information Technology. Ministry of C&TT, Government of
India; in SAS Nagar. We are working towards linking three tertian; level hospitals of North India
namely .

1. AH India institute or Medical sciences at New Delhi.
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System Fnnineer-cum-Cdordinater for this National Telemedicine project at CFDTT SAS Naoar.
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state or Uttar Praaesn) are a mono ven/ rew Indian cities which enjoy henetits or me state-of-theart rommuniratinri terhnnlonip’; like TxDN leased lines etc The project is currently in the terminal
stages of the developssont. It would enable the exchange of clinical information among the three
nuspiiah via ISDiv lines. Tccimuiuyy iui inc udnsfci of data uvci POTS Fids disO been developed
and is currently in the lab testlna phase. The three hospitals beino linked in the pilot project are
referral hospitals end the tpchnolony from these referral hospitals would flow down to the
secondary and eventualiy to the primary healthcare delivery level.
Al CEDTL SAS Nagar we have named trie development as "Sanjeevani" - an iniegtaled
Telemedicine application software. It incorporates latest software technologies to reap the most
offered by Telemedicine. The foremost requirement of any appiication of IT in Medicine, in a
uCvCiGping vvUnu y, io unn tii»_ appiiCvttiGn should be user fncridiyy maiFuy because the medical
fraremiry is nor reennoiogy savvy, ^ameevani is extremely user fnenciiy, besines neing user
friendlv. it supports a comprehensive patient medical record. DICOM imaae format, video
conferencing, standard P/VAIM interfaces for webcams, digita? cameras and scanners and offers
tools for image enhanccrricrit as well. Sanjccvani would form a dedicated Telemedicine network
among rhese three meaicai insnrures

For Teleradiolony - Sanjeevani supports capturing of images in common formats including DICOM
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between those two which will be described in this article.
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Two different kinds of technology make up most of the telemedicine
applications in use today. The first, called store and forward, is used for
transferring digital images from one location to another. A digital image
: is taken using a digital camera, (’stored'} and then sent' 'forwarded”1 to
another iocaiion This is jypicaiiy used for non-emergeni siiuaiions.
when diagnosis r>r cnnsriitatinn may He made in the next 24 - dg hours
and Svjii back.

The image may be transferred within a building, between two buildings
in inC emiiv

CT v. or front one location to another anvwhcrc in the world.

1 eleradiolosv. the sending ot x-ravs. C i scans, or MRds (store-andforward images} is the most common application of tclcmcdicme in use
toaav. mere are nunareas of medical centers, clinics, ana individual
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Telepathology is another common use of this technology Images of
paLK/logy slides mav be sent ironi one location to another lor diagnostic
consultation. Dermatology is also a natural tor store and forward
tcchnclcgy (although practitioners are increasingly using interactr/e
lecnnoiogy for dermaToiogicai exams). Digital images may be taken of
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Pune. May 3 - i nose living in interior Pune villages will now be able to avail expert medical
council well within their means, thanks to a unique telemedicine program.
The P'.'nF disfrirf edr-ninisfr^hAn

teamed up with www docmrgnyvyhRrF com Pnd Tpfja Council

"'■/ ihitmtivss ,. UL!) to launch 2 tsiemsdiems service from 2 government primorv
nediii'iudre Gei itef (rHC ;.

I he service, says the Chief Executive Officer of Pune district administration v. Kadha, will reduce
the travelina time and exoenditure of the ncor villacers.
! he viiiagere rush to big cities to meet specieiist doctors. Since their reiotives o*^ 2 c'*'{’> fnpjjjrv /
the pg:;c;-.;c, the coct
ep. The ocrv;oc icenahcd at three primary health eent^.^ ie targeted
at trie furai masses, n.auria iuiu iANS.

There are 38 PHC’s in Pune district, each manning five to six sub-centers. The PHC's are
manned by two dorters each and equipped with basic medical facilities includina operation
theatres, laboratory and ? pharmacy. The staff consists of 'o personnel who travel to the ^”bcenters to impiem^nt govornmont programs on primary he«;th. vaccinations, leprosy and AIDS.
i ne teiemeaicine project sne said, win ultimately connect ail me Phu s m me district in me first
phase, three PHC's in Waqholi. Chakan and Paud regions would be linked with the district
r,f Pune end the snecialists
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presenr at me neaeguarrers wno can respond even it mere, are no speciaiisrs

As oart of the project, a two-dav training program was conducted recently for 12 doctors.
Amording to Chet^n Shetty of dootoranywhere.corm ‘These dn<?tof s eloog with the
doctcronywhore team will tram the key ucers ct the computer and impart training about the
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t he success of the telemedicine projects at Aragonda in Chitoor district and at Mahaboobnagar General
Hospital over the last two years has spurred the State Government to push for telemedicine links with all
districts. Speaking to The Hindu. K. Anji Reddy, Director-General, AP Vaidhya Vidhana Parishad, said
before the end of 2003 the Government plans to connect all district hospitals with super-speciality
hospitals in Hyderabad through telemedicine.

The APVVP has fixed low, and even free, user charges on various facilities to be provided and
supcrspeciality hospitals of Hyderabad have been allocated different hospitals to link up with.
Dr. Anji Reddy feels that telemedicine is the perfect vehicle for a successful implementation of the
private-public partnership in extending health services to the districts.

Apollo (Karimnagar) and CARE (Mahaboobnagar) already have telemedicine links with district hospitals.
Nizam’s Institute of Medical Sciences is on course to link up at least one district hospital before the end of
August. CDR Hospitals too has plans to link up two districts.

It is through the development of software and the spread of communication infrastructure that
telemedicine has actually become a public health possibility from being merely a technology
demonstrator. Images transmitted over ordinary formats have too many distortions for medical use and
there were problems of slow network speeds. Most importantly, integration of images, graphics, texts and
voice in real time has often proved an obstacle to spread of this technology.
K. Subbarao. Director, NIMS says that the medico-legal aspects of telemedicine have still not been
properly worked out. "Who owns the images and accepts responsibility for diagnosis made on the basis of
these images," he asks, fill recently almost all the images transferred were not on the DICOM (Digital
Imaging and Communication in Medicine) format which is the only internationally recognised format for
medical image transfer. Moreover, most of the machines in use, like CT Scans, Echo colour Doppler and
ECG, were analog based and thus not DICOM compatible
Apart from that there were problems with bandwidth — either it was too slow and unreliable or expensive
and impractical. As recently as November last year the CARE link with Mahaboobnagar had to depend on
the VSAT satellite link which cost upward of Rs. 27 lakhs to install and about Rs. 1 lakh to maintain
every month.
The Mahaboobnagar telemedicine link is now working on a BSNL leased line of 2 mbps on its optical
fibre cables network and costs about Rs. 25,000 per month.

Says V. Giridharan, Managing Director, Karishma Software Ltd, the software solution provider for the
CARE - Mahaboobnagar link. "We can set up a completely functional telemedicine link, with integration
of all high end diagnostic machines, video conferencing and online medical records availability, between
any two centres in less than one week." The cost of the computer equipment and software too has come
down to less than Rs. 7 lakh per centre.
The software links the high end diagnostic machines at the remote centre with the super speciality centre
through real time transfer of images along with a parallel video conference between doctors at these two
centres. It is this clarity of images and the possibility of interactive communication betw een doctors
engaged in diagnosis that has set the benchmark in telemedicine.
The possibilities provided by this software solution has emboldened C?JTE to extend telemedicine links
as far as Orissa and even Assam.

The Government of India has plans to spread telemedicine all over the country. R.R. Shah, Secretary,
Union Ministry of Information Technology, told The Hindu that the Government was even considering

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baiidwidth for this project. Andhra Pradesh can feel proud at having been

m the tore front of this technology driven initiative, whether it was Apollo’s
technology demonstrator at Aragonda or the Hyderabad based Karishma
Software’s DICOM biised solutions which even got a pat from onr President a lew weeks ago
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India: Teiamedicina’s Great New Frontier
An indigenous technoiogy effort is wiring up its healthcare system
By Guy Karns, Secretary, International Society tor Telemedicine

Champions of telemedicine,, the systematic application of information and telecommunications technology to the
practice of healthcare, have been very patient. By the 1980s, pilot projects begun amid great hopes in the 1950s
and 1960s had fizzled out for the most part. More recently, however, telemedicine has undergone something of a
resurgence, as technoiogy has begun catching up with aspirations. Perhaps nowhere is this renaissance so vitaiiy
needed as in India.
With their dependence on high-bandwidth real-time technologies most telemedicine projects of the past decade
have been ill suited to India. Now. though, new hopes are being engendered there by the confluence of lowbandwidth telemedicine with a growing middle class, an improving telecommunications infrastructure, a world-class
software industry, and a medical community open to new ideas.
The facts on India's healthcare situation are sobering. With a ratio of one hospital bed for every 1333 citizens, the
huge country is far nenind even tne Philippines, at 1:600, let alone the United States' 1:212. To get to a more
reasonable 1:500 ratio would reauire the annual construction of 700 new 250-bed hospitals for years to come.

India has one doctor for every 15 500 people. But most doctors live in cities, whereas 70 percent of the
subcontinent's population of just over 1 billion lives in rural areas.

Figures on the percentage covered by health insurance vary from 3 to 9 percent For the hundreds of millions of
poor Indians, healthcare is nominally a government responsibility. But spending on healthcare represents only 0.9
percent of gross domestic product as against around 14 percent in the United States.

1

The basic unit of the public system is the Public Health Center, which is typically staffed by one or two general
practitioners and 10 or so nurses. Each of the centers has a few beds for simple in-patient procedures and perhaps
X-ray and lab facilities There are oniy about 23 000 of these for some 600 000 villages. Above them in the
healthcare hierarchy are district hospitals and, in a few cities, multispecialist hospitals. To get care, those who can
afford it typically spend days traveling.

Another complicating factor is that India’s government-run healthcare system must coexist with hospitals run
bypublic and private trusts and with an active private sector, which caters to middle- and upper-class Indians and
can pay salaries around 10 times the public rate Even the most prominent private group Apollo Hospitals
manages only about 4000 beds throughout the country. There is no doubt that countless men, women, and
children could all benefit enormously from telemedicine.

3

Technical ministries take the lead
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Two government institutions are leading the way. One is the Indian Space Research Organisation (iSRO). The
other is the Ministry of Information Technology, which already has 200 sites used for telemedicine and other
purposes. Trie sites are linked by 128-kb/s integrated-services digital networks (ISDNs) or by satellite and offer
occasional videoconferencing for medical teleconsultation and education.

The Ministry of Information Technology's National Informatics Center plans this month to bring on-line a 384-kb/s
iSC’N linking three teaching institutions, the Sanjay Gandhi Post Graduate Institute of Medical Sciences in
Lucknow, the All-india Institute of Medical Sciences in New Delhi, and the Postgraduate Institute of Medical
Sciences and Research in Cnandigarn me purpose of the networK is collaborative medical education and
research.

in a monthiong hookup after an earthquake, teiemedics transmitted data on 750 patients to specialists 300
km away
In addition ISRO plans to launch the statewide Orissa Telemedicine Network to provide physicians in this
impoverished state with teleconsultation and education programs. The agency is also launching telemedicine
projects in several other areas that have been particularly underserved by healthcare professionals: the Andaman
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iSRO has also provided access to its V-SAT (very small-aperture antenna) communications infrastructure Apollo
Hospitals’ new, small hospital, based in the village of Aragonda, is one V-SA! user. ! he 40-bed hospital was newly
built and equipped with modern computer tomography, ultrasound, echocardiography, automated laboratory
equipment, incubators, and electrocardiogram equipment. A. pediatrician and a general surgeon were made
available in addition to generalists. Using both store-and-forward and real-time technologies such as
videQuunfefenoing, some 200 leieuonsuiis have been provided to this viiiage alone from specialists in Chennai,
formerly Madras. Data is managed through a locally developed software package, Mediscope.

This last indicates a characteristic of Indian telemedicine—it is a largely indigenous affair. India's prodigious gift for
information technology has produced world-leading software and systems, obviating the need for expensive
imports. The range of systems developed is already wide, among them assorted mobile vans equipped with basic
parient monitoring (iike eiecrrocaraiogrsphs) and short-range wireless communications equipment. It might even
serve as the basis for an export industry, particularly to other countries with limited IT infrastructures.

Successes on a large scale
Can telemedicine really make a difference in India? Two recent events suggest it can. The Guiurat earthquake on
27 January 2001 devastated the western city of Bhuj and ieft thousands dead and many more homeless. Within 24
hours the Online Telemedicine Research Institute (OTRI) in Ahmedabad. about 300 km from Bhuj, had established
satellite telephone links between an emergency command center in neighboring Ghandhinagar and various
facilities around Bhuj, including one housed in a tent.
In one month, the hookup transmitted to specialists in Ahmedabad approximately 750 sessions involving primarily
X-rays and electrocardiographs of patients in the disaster area. After two days, the satellite phones gave way to the
more economical V-SAT (which requires a 2-meter dish), with phone lines and ISDN being added as infrastructure
was repaired. Much of the imaging and data transfer was mediated by Pentium 3-based PCs. Eventually,
engineers established a full-fledged telemedicine system supplying teleconsultation in pathology, radiology, and
cardiology over ISDN lines between district hospitals near Bhuj and others in Ahmedabad.
The second encouraging project was carried cut during the Kumbh Mela, a Hindu festival held every 12 years that
last year drew 25 million pilgrims to the banks of the Canges River. Here, the OTRI and the Sanjay Gandhi Post
Graduate insiituie estaoiisned a siation unaer ihe sponsorship of the Ministry of information i echnoiogy to monitor
levels of cholera-causing bacteria in the river water. Microscope images of samples of microorganisms from the
river were transmitted to the Institute's experts in pathology and microbiology for identification and analysis. In
addition, radiology and cardiology data was transferred to specialists for the total of 202 pilgrims who fell ill. The
project ran for 45 days.

Interestingly, it is the engineers and technologists, not physicians, who have pushed hardest for telemedicine. "The
Ministry of Health has not started any activity, not even R&D," noted professor Saroi Mishra, head of Endocrine
Surgery at the Sanjay Gandhi Post Graduate Institute.
Pathologists have been something of an exception. Just this past December, the Indian Association of Pathologists
and Microbiologists organized a symposium on telepathology at their annual conference in Mumbai (formerly
Bombay). Among other topics, the more than 500 participants heard a forma! announcement of the establishment
of a free consultancy, at telepathologyindia.com, providing second opinions on diagnoses from a range of Indian
and international experts
A number of other dot-coms are in the game, including DoctorAnywhere.com. a Web-based service through which
more than 1000 physicians in private practice now consult with specialists. In April of last year the service was
offered to the public health system at no cost, beginning with a pilot program at a Public Health Center in Wagholi,

near Pune, in collaboration with the ! ata Council for Community Initiatives, the humanitarian arm of the country's
largest industrial group

Perhaps the greatest lesson of India's recent telemedicine experiences, and one applicable to any developing
country, is that a lack of physical infrastructure no longer precludes the development of an effective healthcare
system. Tne west s resource-mrensive speciaity-care institutions, the cornerstone of industriai Age medicine are to
a large extent obviated in the Information Age by telemedicine. India can be the template for a new kind of
healthcare.

Acknowledgments: The author wishes to thank Milind Purandare. Zakiuddin Ahmed. Srikrishna Sharma.. Ragesh
Shah. Leonid Androuchko. Saniav P Sood. Sunil Kumar. M.K. Baruah. and Saroi Mishra for their advice and supp

Te!e-medscine Vision

Our Vision is to provide a model of Telemedicine, which self propagates
throughout India and into the developing world. It will provide a channel for
, continuous access to the most sophisticated medical support systems, at al!
times. Further. Telemedicine shall improve patient care, enhance medical
training, standardize clinical practice, stabilize costs and unite clinicians
worldwide.
Apollo Telemedicine believes that this will only happen with the usage of userfriendly technology that is cost effective and scalable.

Offering medical advice via remote communication networks has grown to
become an established service in the developed world and Telemedicine has
been recognized by the World Health Organization as a cost effective.
practical method to deliver healthcare to all.
India, owing to its vast expanse of land, has its population scattered. Of this,
trie availability of heaithcaie facilities is not evenly spaced but is region
specific ana very onen me majority of me population aces not get me benefit
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Teiemedicine allows us to present a time based but value-added, model that
efficiently utilizes the scarce resources allocated for healthcare services.

in India, ! elemedicine wii*. in addition to health related referrals:
Aiiow for it to be used as a channel for communication.

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Now that tele-medicine has made its debut in India, patients are counting the benefits,
rainer man me costs

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illness is no longer a nightmare for those living in the remote villages
surrounding a non-desenpt town m the Chittoor district of Andhra Pradesh.
. Gone are the days when they had to rush a sick villager in the middle of the
night to a city hospital hundreds of kilometers away so that his or her life could
be saved. Now, the new hospital in the town has access to the best medical
treatment and expertise available anywhere in India. Actually, what the hospital
offers is the ability for in-house physicians to consult with experts and
specialists from top hospitals in Chennai and Hyderabad without traveling to
those cities. Welcome to telemedicine in India!
And telemedicine under Indian conditions won’t be limited to remote consultation and
referral services -- it can also bo an important tool for public health administrators.
Telemedicine has a var iety of applications in patient care, education, resear ch, administration
and public health. Plus, home monitoring of patients is attracting much attention. “With this
technology, we may be able to realize the goal of "Health for Air faster than with traditional
means,” commented an IT Ministry official, in fact, the World Health Organisation (WHO) has
recognized telemedicine as the means to deliver healthcare to all.

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India’s first telemedicine project in the commercial arena was launched on April 13 at .Vagonda
viiiage (Andina riadrsii. South India) using satciiite and cuinpuiei links. But tiial was just die xurtruwii* •.n<i-x4awir.Ai»is»c
beginning. A series oi sucn projects win soon become operational at several other locations,
brinsina top-class medical treatment to the doorstep of the rural masses

the villages around A_ragonda were being served by local practitioners and a
govcrnment-iiia Primary Health Center (PIIC), manned by a single registered doctor. Under the
icirmcdicine project, the private sccior irospiiai chain, Apoiio Hospitals Group, iras sei up a 50bed telemedicine center equipped with facilities like operation theater. Cl-scan, X-ray and an
integrated laboratory. The center has been connected via satellite to Apollo’s specialized
hncniraiQ pt Hvdori’bnd and Cnenn^i, noth of which located several hundred kilometers away.
T’tith tmw

Using special hospital information software and hardware, doctors at the telemedicine
center can scan, convert and send data images to (eleconsultanl stations al hospitals in Chennai
and Hyderabad. The facility will be used tor seeking referral services, second opinion, post
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acute care, interpretation services and health education. For these services, villages earlier used
to go to a leaching hosphai located more than 100 kilometers away. "The idea is to take modern
healthcare even to the remotest village, using advances in information technology,” says Dr.
Prathap Reddy, chairman of the Apollo Hospitals Gioup.

lhe group has plans to extend the facility to cover 12? PHCs, 25 district hospitals and three
ieiuai v cciiteis in live siaicS. Vvc lived io wiineci aii the dlice levels of the hcaiiiicdic System
in order to reap mu benefits or telemedicine, in this endeavor, private and public sector should
work together,” savs Reddv. Telemedicine, he savs, will improve patient care, enhance medical
irMirnrK- <J MrwiMr (h se* ciirttCMi niHclirPs mtiH sf-thiii/e r(>S>S.

Uhc project has drawn attention oi the President Clinton. When he briefly stopped at
Hyderabad iriis March, ire checked our tire derails or die leiemedicrire miiiaiive. I liuuk it is a
very wonderful contribution to tne neaitneare oi people wno live in rural areas and 1 nope that
people all over the world will follow vour lead — because if wc do so. then the benefits of hish!Ach mpnirinp can on tn pvwynr’ty ?<nn nnt j’iKt tn n^nni#* who live in big cities/’ Clinton
commented while at the Apollo kiosk setup at Hyderabad’s ?4ahavir Hospital, where he
dcuveicd mi addies^ Uu iitdiinig AIDS iuid iiir)ei CuiOStS

Other Initiatives
Apollo is not alone in the telemedicine endeavor X’iiayawada, another city in Andhra Pradesh, is:
the site of yet another telemedicine initiative in the private sector The project at Tadepaiie is
being executed by the Soumya Medical International, floated by NR1 entrepreneur-doctor G
Suiesh. The company is setting up a iemote rnedicai diagnostic system for the lurat popuiation.
1 he project will cal! for a core center at Vijayawada, and the creation of five regional diagnostic
centers in surrounding districts, which will he linked to 100 general practitioners. If successful,
rh’\ project would address rhe need of approximately one million people The core center, a 250bed hospital, is nearing completion and likely to be inaugurated soon. The Technology
Development Boaid (TDB). an aim of the Ministry of Science and Technology, has extended
financial support to the Ks 100 million project by shouldering 50 percent of the cost

The Ministr.- cTInforrnatiori Technolosv has alreadv initiated a TechnGlG~v Development

..

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Iha’ n 1C1 j7xj pnri .'iiat-im ^C-CphonC 111105. yUlCC ihC *??.S1C

of..x.x_■ si 11 i. ■ has been dcveiopesi, Suon a pilot piOjeci. »»ili be lau
■
irnroducing leiemeuicine. v.DaC and CEDI, scientific societies 01 the ivimisuy, aie the
implementing agencies, imna.uv. three premier medical institutions at New Delhi, Lucknow and
%vChandisarh will he connected for realizing tele-diagnosis tele-'Cpnsultancy and tele^educatiom
Afirh of th aca •nf-tk'Jies , v’ii be connected to one hosnited at nearby ronm. "We are looking
iGi vuSi-vavvn *v SGiuiiv>i'u. v/m iiiani vuiivtiii uv/vv ib iv> liud v»avS LU iiialw iCiduvU-iCuii.'

nifutdabiv. says Saiada KanjanDas. seniui diiectoi, 11 ivimisuy. The institutions to be
networked are the All India institute ot Medical Sciences, New Delhi; the Post Graduate
Institute fPGTY Chandigarh: and the Saniav Gandhi Medical Institute at Lucknow.
Dr. b’.cdd*.' commented that telemedicine could radically decrease healthcare costs. First, the ;
CC'Sl G1 ij it v v i i iic. iG jilciikii vmv.5 iv>i vafv '»Guiki l)< cinuv/oi x.Su'v S i\C<iG_» ,

^illCilciilS

iiving in ruiai areas! lend io spend much more on travel and slay of the family than the patient's :
medical bills." Also, hospitals will have a location cost advantage; it is much cheaper, after all,
io set iii* telemedicine centers in smaller towns than to open hospitals in large cities Government:
statistics, show that up to 80 percent of the healthcare facilities, in both urban and rural areas, are :
in the private sector.

Gening Wired for rhe Xew Age
country like India, there needs to be more than just one technology option. While the IT
Ministry is trying to set nn dial-nn ISDN lines Apollo has gone in for a satellite link provided by
the Indian Space Research Organization (1SRO) on its INS AT series of satellites. In fact, on the
latest Insat-3B satellite. 1SRO has allocated Uansponders for specifically for telemedicine, for
lhe first lime.
A couple of years ago, the National Informatics Center (NIC) piloted a telemedicme project
iisjng its natiorj-wide V> AT nerwork ”TSRO ha< given the satellite 'ink toi two yeais We also yy-ff
have other options like landlines. A lot of bandwidth is going to be available very soon
and gg
WC iiaV< bCvii pfullnscd a Li w float on tliat,’ bays Reddy.
bar me Indian sohware companies. Which have been delivering packages and services for The
healthcare sector in North America, arrival of telemedicine presents new opportunities as well as
rrixi i^TiLTt* IrniiMri

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telemedicine succeeds, -t would perhaps the most visible face of application ot 1! tor the masses

Do you have conir.'.or.ts about this artioJe? Please give us your rEEDSACK'

TELEJ/IEDICINE IN ANEvUvlAN & NICOBAR ISLANDS
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i he mme rhnister, Shn Atal Bihan Vajpayee launched the much awaited telemedicine project on
drd July, ZOO' tor the people or the A & N islands by being in Delhi where he dedicated to the nation
the TNSAT-^C at Delhi Perth Station of Department of Spare, which has linked the G.R. Pant
Hospital, Port Biair with Sri Ramachandra Medical College &’research Institute, Chennai, a Deemed
uiiivtjisiiy wiui supei specidiiy iiusuiidi. outluitaneuusiy. at Poit Biair, the Telemedicine Centre was
inaugurated by the Lt. Governor, Shn N.N.Jha same day at a function organised in this connection at
thA G R Pant HoqnitAl Gomnlpx

■^^■■■\

:«•

i he Indian space K.esearch Organisation has the main objective of using space science and
fpchrir»lr>ijy for nraccroritc; IpvpII aonlirations Today, tNSAT and IRS (Indian remote Sensing)
iauncr.cd i:y iLi’U, arc being
”~r used
yJ for various applications
..
; -- communications,
communications, including
including
those to remote anti inaccessible areas; teievision broadcasting. including developmental education,
meteorological services;disaster warning and natural resources sur/ev and management. New areas
of space applications continue to he Explored by ISRO.

One of the recent applications of space technology initiated by ISRO is in the field of
telemedicine to provide expert medical services to the rural and remote areas. Under the
Telemedicine project, Hospitals/heaith centers in remote locations are linked via INSAT satellites
with super specialty' Hospitals at major towns/cities, bringing in connectivity between patients at
remote end with the Specialist Doctors for medical consultations and treatment, lelemedicine pilot
projects ar^ undertaken by ISRO with the involvement of selected suner sperialtv hosoitals located
in major cities and smaller health centers in distant and rural areas.

i eiei i leuicii ie system consists of customized medical software integrated with computer
hardware, alone? with medical diagnostic instruments connected to the commercial v'SaI (Ven/ bmail
An^rtiirP T^rrriir.al' nt parh lrtrstir.r< General’v, thp medical rpcord/hi«;tnrv of the oatjent is sent to

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gnosis and treatment during

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THlpmAdicinA hHlps p^tiants in distant and rural areas to avail timely consultations of Specialist
Doctors without going through the ordeal of traveling long distances at large expense. The facility
caters normally for transmission of patient's medical images, records, output from medical devices
and sound filps.besides live two-way audio. With the help of theses, a Specialist Doctor could advise
a Doctor or a paramedic at the patient s end, online, on medical care or even guide the Doctor
during a surgery, in die context of distant and rural areas, the telemedicine-based medical care is
also highly cost effective.

Sri

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or! Ramachandra Medical College Gt Research Institute (SRMC & RI), Chennai was established by
Shn N P v Kamasamy Udaya in iy85 as a 'not for profit’ Trust for medical education,, health care
and research The instHjjte, spread over an area of 175 acers, has been recognized as Deemed
University since 1991. ! he College wing of SRMC & RI, with about 5500 students, offers Graduate
and Posi-giauuale courses in vaiious Medical and Para-medical Sciences, and super-speciaity
courses in Cardioloav. Neuroloqy, Neurosuraery, Genito-urinar/ suraer/ and Cardio-thoracic
surgery The Mo^pltal wing r.f th* sswr a pt has over 1500 bed and about 250 specialist Doctors

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! ocated in the premises of the historic Cellular Jail the G R Pant
Hospital at Port Biair is the only referral hospital for the entire group of Andaman & Nicobar Islands.
Scl-up initially in 1963, trie Hospital everyday. The Hospital now has about 40 Doctors includina a
few specialists. Super Specialty sen/ices in cardiology, cardio-thoracic surgery, neurology,
nephrology, gastro-enterolngy. urology, plastic surgery, etc. are obtained from the mainland. A & N
Administration also provides Air Ambulance Services to patients with medical emergencies.

Other Space TechnclGgy Application Project/lnstiatsves in Andaman &

Cr-.^ctal 7nnc»

PlAnc

Biodiversity Characterization at Landscape I aval

Fisheries Potential Forecasts
bpace Museum at Port Blasr

Remore Sensing Cen ar Porr biair
Sdleii’ite based Cornmunicaiions Back-bone for the Isiands- for administration and
teCiii’ncdi cduCatiOn

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Colleae & Research

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Aragonda Appollo Hospital, Chittoor
, District, Andhra Pradesh

Na ray ana Hruaayaiaya,

: District Hospital, ChamarajanaQar
Vivekananda Memorial Hospital,
Saragur, HD Kote Taluk,Mysore Dis.

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All India Institute of Medical
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: Cochin

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Guwahati Medical College & Hospital

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Samay Gandhi Post

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This htuoduciion io ieiemedicme is based un a presentation given by Dr, Susan Zoiio, Director of the Teiemedicine Resource Center at
inc uitiveibiiy ui' ivwa. Cunuauu su$»ai.rT4yij.yj^Al.LV.Yy.5?.:cdu

.ll,cAl^t^ut?.10LHediCl,ie

ceiernedicine as "■■•the use of electronic information and communications technologies to provide and

SUppvi l iicaiuii vai <= rviicij Uiatcii it-c Scpaiat.e5 m i«s pen\ivipoi ivS...

T hp mnqt rnmmr.n

;<-ar.i.iT.i<^u-in r.r hinh-r^nhiHnn Y-rsv^ rar.rthnnAd;,

.Herniatriknr.v and

.. Often, Interactive
.
,rc~:vc video
vidcc and audio are used Z; patent consultations and guidance oh procedures; som^t
briefings and records cf specific operations are kept on a network in digital form. Groups of physicians, teachers and researchers often
"meet" across large distances. Telemedicine also embraces the management of electronic patient records, access to libraries and
..databases on the Web and on private networks, and extensive use ofermall by many in the medlsa! profession.
.

Telemedicine arose originally to serve rural populations, or any people who are geographically dispersed - where time and me cost of
travel make access to the best med'cai cam difficuit. Now, it Is increasingly being used in mainstream medicine, to allow doctors the
world over to share expensive resources and valuable experience.
Tpiemedicine Is Increasingly glohei in ire rppeh; in log? there were 188 active programs around the world, including Israel, Chiie,
India. Taiwan, Japan and the USA.

leiemeoicine is increasingly gionai in its ream: in 199/ mere were 188 active programs arouno me world, including Israel, Chile,
inaia. laiwan, jauan ana me ubA. me avaiiaDinty or ceiemeaicine is aepenoenc co a targe aegree on telecommunications, ana on high
uaiiuwiuk.il, ii ic iieiu is uui ii_ei i icu wilii auvaii^eu leiecui 11111 euuipiiiem. ai iu siaiiuaius, iiicuiuus ui iiiciea^iiiy eiieuuve uai iuwiuIi i at iu
i icivvui ik pet tui t Hat ivc, tusks ut n ouanauivi t aitu vpciaviuti, Scvutiuy, uut niuciHiaiit.y diiu i ciiaumly, ai iu yvh.ii yuvci fill ici iu icytSialiui i
aimau civ iMiuicitiiy

111 nicoc aicao,

the iiiipurtanCc of bandwidth ti jy be seen in a simple example. With a 28.8 Kbps diai-up connection, transmission of a standard Xwith a high speed D33 circuit, It tuxes 1 second. Clearly,
Im, takes zz minutes; with g T: linc at 1.5 Mbps It tukes ZZ
productivity and usability of tel. medicine date depends on the a-,Pliability of high bandwidth.
In. the Middle Zest, Grccnctu; is dcmor.str .ng how high-quality medical care can be brought to virtually any village, powered by solar
sc date cemmunisztiens. This demcnstrztien begins with the visit by the President of the United States to the region
energy and wircicci
8, as part of the ongoing peace process.
in December, 19??
Dr,

ha fid Mnidu, an ady^cAr t«

on reiomodicinA, adds to this narrative;

The earliest example of telemedicine was -n the physiological monitoring of astronauts, through pioneering work, done by NASA. The
Gemini and Apolin ^stron^iirc in the 1960‘s had two-way video connections with space medic?! experts in Houston, and developed a
quite natural mode of interaction from orbit that featured taking care of routine health questions and needs, and early experiments on
the effects of weightlessness.
This was followed by trials at Boston's Looan Airnort. and participation by native American reservations in the STARPHAC orooram.

Telemedicine in the developed world is really "virtual transportation." In critical situations, the ability to keep a patient where he Is
and not have to stage an emergency evacuation, with all Its costs and dangers, can be vital to the patient's survival and ouality of life.
But in the developing world, telemedicine delivers access to a high level of care where It is simply not available, at any cost.
So Greenstar, with its built-in infrastructure of power and telecommunications, delivers the platform on which telemedicine can exist
In the developing world, and through which knowledge and experience can be effectively diffused.

See more articles at: http:/,^YWw.qreenstar.prq/te!em.ed-.!ntrc..htm

TEJ

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Uepi. of Defense. Beuiestid Nave! Medical Center

Dect. of Defense, Joint Imaoino Project Office, Ft. Detrick, MD
Dept, of Defense, Space and Navas Warfare Systems Center, North Charleston SC
rlOuHLdif'i A( ec i i cgi<_ii iZU Cei itci, Asheville, NC

DeKalb Medical Center, Philadelphia, PA
Fast OAuilin^ Medical Center, (T.^envi'le, NC

Bowman Gray Medical Center, Winston-Salem, NC
University of Arizona, Tucson, AZ

*

Arizona Telemedicine Program, Tucson, Az'
emergency Medical Associates, Booten ! ownship, MJ
veriCOi r'ietebuiic Sei vices, Luuisviiie, KY

St. Joseph’s of the Pines Hospital, Southern Pines, NC
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Richland Memorial Hospital, Columbia, SC
Johnson City Medical Center, Johnson City; TN

Co'lcgis, Raleigh, N
Mission Sr. Joseph's i-teaitn system, Asheville. NC
m^n^r. Dc:i.nc;Sucj, Pio

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Alaska Native Health Board, Anchorage, Alaska
5ui ini nccithCcJic Systems, vVcke rui est, NC

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Halifax Regional Medical Center, Roanoke Rapids, NC

Dunlin General Hospital, Kenansville, NC

Concurrent lechnoiogies Corp., Johnstown, PA

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Goshen Medical Center, Faison, N
Punqo District Hospital, Bellhaven, NC

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National Rehabilitation Hospital. Washington, DC
Radiology Department, US Navy, San Diego, CA
VTEL Corporation, Austin, TX

Consortium for Worker Education, Health Care Institute, New York, NY
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Shriner's Hospital for Children, S^lt Lake City, UT

?he riong Kong Hniyt^cnnjc university, Hungnoun, Kowioon, Hong k ong
University of Hawaii, Honolulu, HI
St. f-rancis Healthcare Systems of Hawaii, Honolulu, HI

Southern Regional AHFC. Fayetteville, N(

Deniey lechnoiogy Center, Washinton, DC

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Rural Health Group, Jackson, NC
! jniversifv of Marvlanrl Baltimore MO
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The United Utetes Teiemedicine Training Institute, Washington, DC

Medicdi Reseat ch Council oi South Afr ica
Area I AH FC. Rockv Mount. NC

’ ranckoi Eastern Cape, South /Africa

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Univeibiiy uf Tennessee, Memphis, iN

Cabazon Band ot Mission Indians, Indio, CA
Denver Health Authority, Denver, CO
AVDA De La Universidad, Caceres, Spain

Heritage Hospital, Tarboro, NC
TntArnatinnA' Craniofeci^l Institute, Dallas, T?X

Indiana University Department of Surgery, Indianapolis, IN

University of California Davis lelemedicine Department, Sacramento, CA
National Rehabilitation Hospital. Washington, DC

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Radiology Department, US Navy, San Diego, CA

v i EL Coipoidiion, Austin, ia
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Consortium for Worker Education. Health Care Institute. New York, NY
Sh.rinere Hospital for Children, Salt Lake City, Ui

Meliiudisi. Le Duuniieui nediuicdie, Memphis, iN

East Carolina University (ECU) and ECU Medical School, Greenville, NC
Pitt County Memorial Hospital, Greenville, NC
*

Baptist Hospital/Wdke Forest University, Winston-Salem, NC
Mediheip International, Queensland, Australia

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Poopin R^piihlir of China, Malaysia, Indonesia

FUNEN Project, Pune, India and Walnut Creek, CA

The Secretary ot Communications, Argentina

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Mission St. Joseph s Health System. Asheville. NC

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Cardiothoracic Research Foundation, Escondido, CA

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Merck Co., Inc, West Point, PA

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NASA and the Global Telemedicine Group, McLean, VA

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United Therapeutics Corporation, Silver Spring, MD

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TMI Engineering, Houston, TX

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IBC Healtcare Limited, Greensboro, NC

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Isrksrin Hospital lark son IN

University of Paris, Paris, trance
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Sentdia Healthcare, Norfolk, VA

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Nemours Children Clinic, Jacksonville, FL

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Organization Mikocheni Health and Education Network, Mission Viejo, CA

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Alaskanative Tribal Health Consortium, Anchorage, AK

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The Hong Kona Polytechnic University, Hunghoun, Kowloon, Hona Kona

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University of Hawaii, Honolulu, Hi

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St. Francis Healthcare Systems of Hawaii, Honolulu, HI
Southern Regional AHEC, Fayetteville, NC

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University of Transkei. Eastern Cape, South Africa
University of Tennessee, Memphis, TN

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Departmenl of Surgery, Rochester General Hospital
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Eastern Virginia Medical School, Norfolk, VA
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of nniciiCa, Washington, DC

Mission St. josepn s Health system, Asheville, NC

CArdint-hr»r^rir PoKParrh F-Hipdetir»n Escondido, CA
.Merck Co., Inc, West Point, PA

NASA and the Global leiemedicine Group, McLean, VA
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United Therapeutics Corporation, Silver Spring, MD

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IBC Healtcare Limited, Greensboro. NC

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Telerpedical Speciality Consultants, Winston Salem, NC
National Rehabilitation Hospital, Washington, DC
Consortium for Worker Education, New York, NY

Methodist Lexington Hospital. Lexington, TN
Jackson Hospital, Jackson. ; N

Ui ii vei oily of rdi iS, rdi iS, France
Sentara Healthcare, Norfolk, VA
Npmoiirs Children C'inir larksonvi'le. FL
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Orga J ii&.aLiv>i • riirwviiciu i i d <u i i i and Education Network, Mission Viejo, CA

Alaskanative Tribal Health Consortium, Anchorage, AK

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Organizdiion riikucheni Heailii and Education Netwoik. Mission Viejo,. CA

Alaskanative Tribal Health Consortium. Anchorage. AK
Hong K or.g Polytechnic University, Hunghoun, Kcwiocn, Heng Kong
Huiiuiuiu, HI
Uinveibity ui Hawaii,
H

St. Francis Healthcare Systems of Hawaii, Honolulu, HI
Southern. Regional AHEC, Fayetteville, NC

♦

Deriley Technology Center, Washinton, DC

Rural Health Group, Jackson, NC
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The United States Telemedicine Training Institute, Washington, DC

Medical Research Council of South Africa
Area I. AHEC. Rocky Mount, NC
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University of I ranskei, Eastern Cape, South Africa

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University of Tennessee. Memphis, TN

Cabazon Rand of Mission Indians. Indio. CA

A v DA De La Uuivei siudiJ , Caceres, Spain
tqpof_page.[__ '

leiemedicine - Saving Lives in remote
area’s

As five-year-oid Thejas lay m bed in the consulting room at the Aragonda Apollo hospital in this
remote village, about 170 km from Chennai, doctors first diagnosed a murmur in the heart and he
was put on colour doppier.

As the colour doppier imaaes were transmitted to its hospital in Chennai usina special electronic
communication, Pediatric Cardiologist Prem Shekhar diagnosed the case as "Sallot's Tetrology"
(Multiple Congenital defect of the heart). After a few hours consultation with surgeons and hospital
cnairman Dr Prarap C Keody, me cnnd was transferred re Chennai Apoiio hospital for surgery. Dr
O

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nnor^r.-'H rroa nr rncr ^nrl a|| rno ovnancac rir>rncs hx/ rno hrtcrxif-pj

Priyanka (11) was similarly aiagnosea as Having a hole in the Heart and she is being shifted to
Apollo’s Hyderahod hospital for surgery A Philanthropist will bear the cost of the consumables
while the hospital wii! provide its sen.'ices free as a special case.
Di Reudy uuin in
vmaye was feiiieu in a uuliock Cail iu a yiiiTidi'y SCnOOi. In Contrast 5 helipad
is now bema readied to bnna union information lechnology Minister Framed
Mahajan to fnrmal’y rlerlere r>ppn this SO bed hospital, a pioneering venture that will give access to
the best medical facilities in India to Aragons with a population of 4000 as also surrounding
viiidyes with a pupuiauon of 56,000 al a nominal cost.
The public sector oriental insurance corporation, has also stepped in to provide medical insurance
to the villages at a premium of Rs 1 per day. Dr Reddy, who had built Asia's largest private health
care group which is aiso rhe seventh largest in the world, had none it again, this rime by bringing
•n mndorn m-mmi^nrhnnlnrj'-x jjcinr! cnr.oll^csc tn nrnvide cfnt<2 -nf-thss-^rt modim!

rn

rna yjjlgnoc pr

ranncs

. Telemedicine, which is already in vogue in advanced countries, puts health care specialists in
touch with remote clinics, hospitals, primary care physicians and patients and is used for remote
consulting, medical diagnosis, treatment and continuing education. Dr Reddy said while advanced
medical facilities were available in large cities, rural areas at best had only primary health
centers ana the Teiemeaicme initiative made by the hospital was to bridge the geographical
distance and take health care from the people who have it to the those who don’t
Prime Minister Atal Bihari Vajpayee in a message congratulated the hospital group for the
initiative. US president Bill Clinton durinq his recent visit to Hyderabad was al! praise for the
initiative that k eynerted tn revnhitinniTo health cam cielivery in the rural area<; The hospital is

built at a cost of Rs 5 crore and is equipped to provide primary and secondary care.
The Indian Snare Research Oraanisation fISRO) has orovided the satellite facilities and citadel. GE
and Wipro have extended their support-to the undertaking, 't ’nas ai* the ^as’c enu*pmenf to scan
convert ariu senu uata hugmcS to trie teleconsultar.t stations in Chennai and Hyderabad. The
images snail oe compatible so as to achieve universal stanaaraization, Dr Keooy explained. Dr
Reddy said in the phase two of the telemedicine project, 125 primary, 25 secondary and three
torti2p/ cor*.tors ir*. fi*. <~i-nrn<' nf Fvlon'S rashtra, Gujarat, Madhya Pradesh and Jami! Nadu and
Andina Piadesh would be cweied. rhdse three will connect 25G0 primary centers, 300 secondary
and 1UU
tertiary rpnt-rs all nvar thp rnHniTy and attempt to extend thp services to tha developing world.

It will also extend the services beyond national boundaries to connect international centers of
medical excellence with local medical institutions via the telemedicine link. Dr Reddy said the
vision of the .Arariond^ toloroHdicm* ondoavor is to provide a successful working model for rural
telemedicine and its implementation throughout India and the developing world. Telemedicine
initiative iiere is the blending of two worlds—the traditional and the jet set.

international Telemedicine Markets & Business Opportunities
An Afticl*1 from

P^nott

Profsls!
TajS
TjiScss or* Tr«c«Sr«
A small company cut of Newport News, VA is attempting a huge project: Taurus
Technologies -- uiidei the direction uf CEO Aivind Patel -- is trying to yet die Indian
nnwornmpnt tn hi iv infrn a nlan tn incfrall a tloot nt mi iltimnrlia-hacnri kinckc fu/ith catdlitn
V

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w

a a l^>«.V4a a

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rorrirni iniration<;' thtwnnhont th#j s< itv-nritinjjnt

wa

i a iV4ii.li i iv^vaivi

mv«u>m>m

a \i w«za Vh/

\ vr iui i

m

h rtiHao W3V to hnno irppt'OVed health care

to rural millions.
Pstpl^ him<f4f Iwm in India, told (TTP that the government is cpftainly interested hut
that there arc various political difficulties, as a government shift may soon take place. Taurus
isn r rhe oniy company inierested in the project, airhough we cannot identify for certain any
other olavers. fit is entirely possible that a Huahes, say. or a consortium of larae hardware
vendors, communications suppliers and systems integrators is going after the same project. In
this sort of situation one hears frequently the plaint from the small players that the big guys
are only after rhe dig buck -- go a targe demo, take the money, and get out. Whereas, tney,
the people with the time invested and the organic connection to the place are more interested
in a sustainable solution. We make no judgment here because we haven’t the facts - yet.)
Taurus is a systems integrator trying to leverage a background in systems engineering
for nuclear plants into tne iniernaiicnai neairh-care arena. The idea of their contact in India,
evolved with Patel's help, is to flood the country with kiosks equipped with basic diaonostic
support, connected to a communications node that talks to the regional support center, which
in turn Jinks back to a national - and, finally, intci national -- network.
i aurus jod is to put together tne subsystems tor accepting diverse data feeds from
everything from lab equipment tn EKG to radiology sources.
The Tsme and Maney Invaivad
llr tne [political' approvals nappen, we u like to do a pilot project around Delhi in the
next <50-120 days ” Patel informed GTR The rost-per-kiosk would run about 4:150 000 to start
with. Part of the vision that drives the kiosk, idea is that once a working model is generated,
byslenis iiticyiaiuis will bwaim in dub uiivc uuwn die cost.

I he inaian telecom infrastructure is basically being developed along European lines,
with P-1 linex takinn precedence F-1 line*; are in terms of handwidth between T1 and TT A
*1

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Indian concern involved with a number or industries besides telecom) have teamed uo to win
mritraris tn Hrnvirlp infractruftjirp in

TnrtiAn states.

in the U.S., Patel and Taurus now search for component and device

.

nidiluidciuieib wiiUbe piuuuuib tdii be iiiieyidieu into ihe kiosk. 11 is iougii lo iinu

*
*

cooperative vendors who provide data access at the level we need it,” Observes Patel. They
spoken with hoth r^roiTietrics (which does work with Dr. J^son G’ollins, the developer of
an in-home, md/W-based total monitoring solution) tor EKG/ECG, and they also are
aiiempiing io cieai with Beckmann, which suppiies PC-based lab lools. GTR wiii keep you up to

date as thinos progress in India.

□w

i

7

*

I

Cirtn^
•»’ ’

*

HYUbKABAD Juiv 18. Enthused dv ths success in Andhra Pradesh, the city-based
CARE Hospital hes decided to replicate its telemedicine project in other States. The
service has recently been introduced in two centres in Orissa and plans are on to
z- /“.A.
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111

Using safenite communication, the hospital first used the concept of telemedicine to
COi fi icCl SOeCiaiiSu GuCtvi 5 ii i d ie Civy With rlahuLiwi layci vjOVcfrii i lei iu kacHcrci

fer over 1 ,100 DAtients from the district have availed

Mosnitel in Orbnher lech

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LW □CCh MICJMIIWOIO.

The doctors in Mahhubnagar use digital transmission for sending their patients'
clinical information and diagnostic reports pertaining to cardiology,, radiology and
nanrrslnnv for pynart rnncilibation The nrniprb is enuinned tn handle the
transmission of real Lime uala. video,, audio and graphic communication,, enabling
M Z

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I

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nr^rritirjnpr<; tn sahH Fm ijnH and CT-SCrsn
*

I

' tjnee trie ciirntdi infur malion,. dionCJ with images,- comes here, the patient is
examined by the

oacciririthd s» iirUr’iiio ;-’iqr=»{=iiFjrtaHz*’.r=. number. The !nfcr!T!—tion is

experts arid diayriosHti irrirrMdialeiy, CARE Foundation director, Arun ilwari, said.
m
gnH
J. AKrlijI
Abdu! IZKS3 I alam
caruioioaist. b. bomaraiu, nas now none online in two centres in Orissa.
The
District Hospital st Puri end the Utko! Heart Centro, Bhubaneshwar, have been
imKed,; saia nror. fiwari.
T

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The CARL team was recently invited by the Assam Government to develop critical
care infrastructure and also tor a blueprint for healthcare deliver/ in the
;nsurgency-hit areas, the team compiising, L>r. oomaiaju, Ciiairman, CA<\E
Hospitals. D. Prasada Rao, cardiac surgeon, and Prof. Tiwari, visited the State and
held discussions with the Chief Minister, Tarun Cogoi.
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- 36
Trends Clin. Biochem. Lab. Medicine 2003 : 42-48

Telemedicine for Rural Areas
Nerges Mistry and Noshir Antia
The Foundation for Research in Community Health (FRCH),
84-A, R.G.Thadani Marg, Worli, Mumbai-400 018

Abstract: The creation of a community based health care system for rural areas visualizes
the development of multiple levels of grass root cadre of health and development workers
who eventually link up to existent tertiary care services. Much confidence can be generated
on a first line referral for the grass root cadres in the form of a diagnostic software package.
Thus SYMPMED-I was developed by FRCH in 1988. An upgraded diagnostic and treatment
software (SYMPMED-ll-E) has been designed in JAVA with additional features incorporating
clinical examination findings, pathology tests, pediatric doses, drug information and side
effects as well as ancillary information on national disease programmes. The software is to
be supplemented with visual literary material supplied to the village health workers who will
be trained in its use. A description on the development and content of this package for the
internet and its potential for use in rural areas with the aid of telecommunications is presented
here.

Key words : Community health care system, Telemedicine, Software diagnostic package.
Introduction
Both the public and private sector have failed to deliver in the area of health and health care
Whilst the former has rampant unaccountability, the private exploits and both posses practice;
features that are irrelevant to their country’s needs. Much of it has roots in the great cultur;
divide between India and Bharat. The ultimate aim is to build up an alternative form of
health care system for rural areas that is equitable, accessible and cost-effective based c
the principles of decentralization and possessing a graded structure of functionaries.
Over the last 30 years FRCH, a public trust functioning from Mumbai and Pune h<
attempted to conceptualize and demonstrate a people-based form of health care syste
particularly for the rural areas based on the principles of the pioneering Report of 1CSSI
ICMR - Health for All - An Alternative Strategy’, 1981 (1). Its extended experience among
many others has shown that ~ 85% of health care can be undertaken at the community lev
by trained workers who are drawn from the community and who can fulfill both the technic
and socia' demands of health care humanely with full accountability to their neighboui
Women
Women even
even with minimal education, with their intrinsic qua'ity of care and nurture ha
proved to be admirable health workers as well as trainers performing a wide variety
functions both in health and illness care.

A graded form of community based health care described by FRCH is presented
Figure 1. Whilst clinical skills have their place as an inverted pyramid, social skills <
e-mail : frchborn@born2.vsnl.net.in

43

Telemedicine for rural areas

Approximate
Population

Functionary

Responsibility
to

200

Community Haith
Functionary

Neighbourhood
group

Approximate protection of
the total services covered

70%

1,000

Village Health
Functionary

Gram Panchayat

5,000

Sahyogini
(Referral Centre)

Group Gram
Panchayat

85%

Panchayat
Samiti

95%

i

. Curative

Training
Cell

I

Public
Health

People's Health
Complex

100.000

Figure 1. Organization Structure - Community Health Care System (CHCS)

encouraged with the same intensity longitudinally. Training modules striking by their integrated
nature are imparted more in the form of experience sharing and discussion. These have
been now compacted into courses for distant education accredited to The National Open
School. Confidence generating and networking are the keys to the development of health
workers at the grass roots notwithstanding either their socio-economic conditions or education
levels. One of the most important criteria that sustain confidence is the build-up of a referral
chain that supports the first level of workers to handle emergency or diagnosis and referral
of difficult problems (as well as facility of transport) to the nearest centre where appropriate
medical aid can be provided. If such support is not available, it leads to the eroding of
confidence.

The FRCH experience over the past 3 years in the Parinche valley in Purandhar taluka,
Maharashtra illustrates that trained semi-literate rural women can handle ~ 55% of illness
episodes in their community (Fig.2). Whilst providing humane and accessible quality health
care, this has led to considerable reduction in illness expenditure (Fig.3) and generated
useful micro-level health information viz. morbidity patterns, (Fig.4) birth and death records
etc. which is difficult to generate otherwise.

Health information systems exemplified by thesej can form a powerful local data base of
symptoms that can be
L_ transformed to diagnostic algorithms usable in devising IT packages.

Merges Mistry and Noshir Antia

44

Wage looss T

4% PHC

■0 Tail
Dr-

Day loss
J

I

Travel

55%®

Fees jj

Tai

Private
Practitioner

Figure 2. Utilization pattern of grass root
workers (tai) by the Community in 2000

—4100

—I-

0

50

—i—

150
(INR)

—I—
200

—I
300

---- H

250

Figure 3. Comparison of illness expenditure for
moderately severe illnesses (Year 2000)

600
□ 1998

>1999

500'

a

400"

;;v

*;■

300'’

-

fell

200‘’

100”

I

..

I

?■

n <^11^
Respiratory

Si

Fever

f Si

fl
I

r

T
Diarrhoeal
Problems

i
w

Women’s
Aches

11
Pains

r

------------ r

Injures

ii
IS
Misc.

Figure 4. Morbidity observed in a community of 4205

SYMPMED-I was thus developed by FRCH as ? pilot software package in the mid 80s from
;ts experience during the Mandwa project (2,o).
The building block for SYMPMED-I is a single symptom. For each symptom entered the
first step is to make the user aware of other symptoms or signs which are associated with
the presenting symptom and require a doctor’s attention or referral to the hospital. The
remaining steps included probing deeper into the presenting symptoms for elaboration of the
problem. At both testing and conceptualization level, certain shortfalls were noticed :

1.

Trained personnel found this programme most simple

45

Telemedicine for rural areas

2.

There was no focus on examination findings - the reason being more weightage

3.
4.

given
to
therapeutic
satisfaction.
No pediatric doses
There were symptoms that
could not be handled by
SYMPMED-I (Table 1).

However,
the
programme
confirmed that a majority of problems
noticed by first level medical personnel
in developing countries are simple,
repetitive and treatable at home by a
paramedical worker with a few, safe
essential drugs. It also demonstrated
that flow charts which were anathema
to at least our health workers, could
be substituted.

Accessibility to such referral
information to a grass root level worker
in a remote mountainous village on a
computer is a tall order especially
where the advantages of electrical
supply may be snatched intermittently
or extended upto four days. The
inability to seek prompt medical advice
has resulted in several needless
deaths in the Western mountainous
regions of the Parinche Valley.

Table 1.

Symptoms that cannot be handled
by SYMPMED-I

Fever for more than one week
Convulsion
Abnormalities of consciousness
Loss or diminution of power or sensation in any part
of the body
Disorders of eye and vision
Severe pain anywhere in the body
Anything more than mild breathlessness
Bleeding from any organ
Anything more than minor cuts and wounds
Appreciable recent weight loss
Signs presented as symptoms

Anywhere

Pune

FRCH
Pune

Tertiary
care

PARINCHE
BASE WITH
SYMPMED-II AND
TELECOMM BASE
STATION

PHC/TALUKA
HOSPn~AL

A

The system organization of
telemedicine is depicted in Figure 5.
The problem of unreliable electrical
supplies, wide voltage fluctuations and
lack of a repair and maintenance
infrastructure exclude the ideal design
of maintaining computers with
installation of the diagnostic software
SYMPMED-II in all the villages in the
Parinche valley area. Hence in
keeping with the local conditions, a
single computer based centrally in
Parinche village would receive
referrals for the software from selected

L

i
15 HANDSETS

15 Peripheral locations in community manned by VHFs with hand sets for
communication with base
------------------ . Telecommunication
: E mail: Internet

: Patient transport lines

Figure 5. Organization of Telemedicine Set-up

46

Merges Mistry and Noshir Antia

areas in the valley. The telecommunication equipment as well as the computers will eventually
be in the charge of senior women health functionaries (Sahyoginis) who will be trained to
operate and maintain the same.
A grant from the Department of Electronics in the mid 1990s tested the feasibility of using
citizen band (CB) radio in conjunction with SYMPMED-I. The telecommunication hardware
had several technical glitches, low communication time, distortion, time and seasonal variations
and with lack of preventive maintenance, frequent breakdown and abnormal battery recharging.
The equipment recommended to us by the Ministry had a fly-by-night agent who simply
disappeared after sale of the sets. However confident utilization of the CB radio by local
women has been repeatedly demonstrated. This experience paved the way for defining

modified objectives as given below:

1. Development of an expanded upgraded diagnostic and educational software for enhancing
2.

3.
4.
5.
6.

diagnostic and treatment skills of health workers at the grass roots in a rural community.
Explore use of radiocommunications for establishing a local referral network for medical

care.
Documentation and analysis of experience with respect of ,(a) fulfilling the needs of the
community (b) accuracy of referrals and (c) cost-effectiveness
Build-up of local health information.
Use of telecommunications / IT as multipurpose tools for local networking in education
and provision of public information.
Replication / dissemination of experience in other areas of the country.

The design of an upgraded diagnostic software 8YMPMED-II-E has been based on the
gleaning of difficulties in diagnosis faced by the village health functionaries over a period of
time. Strengthening of the pediatric component, inclusion of differential drug dosages, danger
signals at diagnosis and in the post-treatment period are all features in the modified version
arising from a needs assessment. Unlike SYMPMED-I, the programming language is platform
independent and programme aspects are created for putting on the internet.
A diagnosis is aimed to be arrived at through the recording of clusters of 65 primary and
71 associated symptoms, (each with their own confidence level for an individual disease or
condition) examination findings and findings of pathology tests. If pathology tests have not
been done then it advises on which ones to do. The programme incorporates footnotes which
feature drugs from all symptoms of medicines, home remedies, treatment outcomes,
prediagnostic and post-treatment warning signals and national disease programmes. Since
~ 20 drugs are intended for SYMPMED-II-E, a separate folder will provide details on each
of their indications, contradictions, side effects and changes. The storage of patient records
on a longitudinal basis with easy retrieval will be an advantageous additive for the system.
Features for constant evolving of algorithms is intended provided that the system retains its
simplicity for operation by local women.

The earlier experience with the CB radio showed the need for significant improvement
in communication hardware and training of local users in preventive maintenance. The CB
radio has been replaced with an ICOM make Japan Marine Band held transreceiver using
the VHF band of 146 MHz. The tests were conducted with one base station set at Parinche

Telemedicine for rural areas

47

'..'.j a fibre omni directional antenna and a hand held
delivering a power output of 25 watts into
" ; ffor
set delivering 1 watt output. The sites
—. reliable communication have also been identified
in the valley. The key features of
c.‘ the radiocommunication system include:

1.
2.
3.
4.
5.
6.
7.
8.

VHF radio communication
Utility for broadcasting with amplification
Duplex communication
Networking with computers
Long-life batteries
Attachment to a tape recorder
Good voice quality
Robust and light weight.

SYMPMED-II-E will be augmented by printed material that will be distributed to each
peripheral village. Telecommunication from the peripheral villages to Pannche will be through
handsets transmitting to a base station at Parinche. As a back-up for communication P^lerns
particularly in the mountainous area, a second base-station will be set up to provide reliability
in communications so that village in its vicinity can communicate with it for passing on the
message to the base at Parinche.
Training of women functionaries is a key element to the success of SYMPMED-II-E. A
Training of women functionaries is
selected group of village health workers will be trained in.
1.

2.
3.

Eliciting of symptoms from patients
Transmission of symptoms and observations to the computer operator hand i g

emergencies and
.
,
Transportation arrangements and optimal use of printed material (text and
diagrammatic) provided to supplement SYMPMED-ll.

Of these a selected group of workers with enhanced diagnostic skills will be taught the
operations of SYMPMED-II-E through hands-on training at the computer and during s.mulations
of prevalent difficult conditions.
Several modifications to SYMPMED-ll are anticipated before a final version emerges
Unresolved clinical conditions will be referred to doctors manning a clinic at Pannche though
onward referrals to doctors in distant locations is technically a possibility. These local clinicians
will also be software system administrators with capacity to modif;' system rules eg. confidence

values, symptom clusters as well as information in the software.
A strong research back-up is necessary to test the system. A constant analysis of clinical
outcome of the referral is mandatory in the developmental stages to facilitate modifications^
At ground level, reliability of communication hardware and communication skills of the healt
workers will also have to be monitored upon.

The above described approach to telemedicine is tailored specifically to match and aid
the skills of health workers at grass roots. Whilst it can never entirely supp ement the
accessibility to a doctor, its broad information base can be a powerful enhancer of diagnostic
confidence as well as a tool for constant education towards Health for All. Recognition of its

48

Nerges Mistry and Noshir Antia

and educa,lon

rendw"a power,ui ,o°'and np' 'us* a"pih“

References

1.

Anonynwu5 (1981). Health for All: An Alternative Surgery. Report of a study group set up jointly
^y The Indian Council of Social Science Research and Indian Council of Medical Reseach, New

2.
3.

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Antia N.H. (1986). The Mandwa experiment, an alternative strategy. Brit. Med. J. 292, 1181I I OJ,

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