JULY 2010: Farveen lives in a remote area of Andhra Pradesh’s Kurnool district. When a scorpion bit her friend last year, she was clueless about the first aid required. She immediately called 104 Advice helpline of the Health Management Research Institute (HMRI). The practitioners SMSed her the prescription, along with first aid instructions. Thanks to telemedicine, Farveen was able to save her friend.

Neurosynaptic Communications, in close association with IIT-Madras’ TeNeT Group, has set up ReMeDi—a remote medical diagnostic solution that enables doctors to videoconference with patients who come to ‘see’ them, through Internet centres set up in the village
Neurosynaptic Communications, in close association with IIT-Madras’ TeNeT Group, has set up ReMeDi—a remote medical diagnostic solution that enables doctors to videoconference with patients who come to ‘see’ them, through Internet centres set up in the village

Had the situation required detailed diagnosis, the ‘Doc-in-the-Box’ would have come to Farveen’s aid. HMRI’s telemedicine solution looks like a pizza delivery bike, but is a virtual hospital! It uses a combination of medical equipment, communication technologies and software to provide rural patients with access to low-cost yet world-class medical diagnosis and treatment. They do this using virtual physical examination and consultation modules such as tele-ENT, tele dermatology, tele-medical and surgical consultation, tele-cardiology and tele-ophthalmology.

Piloted in Andhra Pradesh, HMRI has deployed its telemedicine technology to provide a primary healthcare physician’s treatment at several old-age homes, as well as specialised cardiology consultation at district hospitals. In a little over a year, it has provided tele-consultation to over 15,000 patients. No wonder, HMRI has been chosen as a ‘social innovator’ by NASSCOM.

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More success stories
A few years ago, when Sameer Sawarkar and Rajeev Kumar realised that 80 per cent of India’s healthcare professionals are in urban areas while 70 per cent of the population resides in the rural segment, they decided to bridge this cleft using technology. After all, not every villager can afford to travel to the nearest township to consult a general physician, let alone a specialist. So they decided to take the water to the horse rather than dragging the horse to the pond, and started Neurosynaptic Communications, in close association with IIT-Madras’ TeNeT Group.

Telemedicine At A Glance

Telemedicine can be broadly defined as healthcare services delivered through telecommunication networks. In simplest terms, telemedicine can be explained as two doctors or doctor-patient discussing the case on a phone. Practiced telemedicine is more than simple voice communication over telephone lines. It is the integration of store-and-forward technology with real-time responses.

Telemedicine is the only solution to provide healthcare services to people in remote locations. Conventionally, the government would need to build hospitals in every village and provide physicians to each, which is an extremely daunting task. Alternatively, we could use IT tools like telemedicine to provide quality healthcare to all.

Technical components of a typical telemedicine system
1. Data acquisition (the capability to integrate with medical equipment and acquire data)
2. Electronic record management (includes patient registration details, history, prescription, lab reports, etc) 3. Video and image conferencing
4. Communication networks (broadband, mobile, etc) for data transfer between remote locations and expert centres

Non-technical components
1. The patient
2. A doctor situated at the remote location who decides the need for telemedicine and links up with the expert for consultation through the telemedicine system
3. A technical operator who handles the telemedicine system, voice or video-based conferencing, report transmission, prescription receipt, print-outs, etc
4. An expert who caters to the telemedicine request from a main centre

Benefits of telemedicine
1. Healthcare services delivered at your doorstep. In urban areas, this means avoiding the traffic. In rural areas, it means the boon of healthcare. The same can be true for second opinions, lab reports, radiology reports, etc.
2. Telemedicine components like Web-based patient health records can be very useful in the case of emergencies.
3. Patient health records prove to be a lifetime medical history and can be used for health monitoring. Prompt reminders for health checkups may prevent many issues.
4. In the case of chronic cases, repeated hospital visits can be prevented.
5. Improved reach to rural areas.
6. Can even be used for healthcare education.

—By Devendra Patel, director, Medisoft Telemedicine

After painstaking research in labs and on the field, ReMeDi was born. This remote medical diagnostic solution enabled doctors to videoconference with patients who came to seek their services through Internet centres set up in the villages. Innovative technologies developed by TeNeT helped to bridge the last-mile gap. Doctors could remotely view the output of probe-fitted medical equipment like electro-cardiograms (ECG), blood pressure monitors and stethoscopes administered by the local operators, store and analyse medical records online, as well as prescribe medicines. In all, it was almost as if the patient and doctor were sitting across a desk.

It was not all about technology though—the duo had to build a viable business model that split up the health care delivery model into various levels ranging from the doctor to the local Internet centre operator to the pharmacists and diagnostic labs, and ensure that it was profitable for them all to stay in business. Plus, they had to change the firm cultural mindsets of people to make them accept a local operator as a healthcare practitioner. ReMeDi is now being used in states like Uttar Pradesh, Bihar and Tamilnadu, and also being piloted in other countries.

Madurai-based Aravind Eye Care is a highly-reputed institution in India. It is known for its research as well as expert panel of doctors who have treated several seemingly-hopeless cases. More than anything else, they are known for their reach at the bottom of the pyramid, all over the country. While they used to cover this population through eye camps in the past, now they have turned to telemedicine as a more permanent solution. Dr S. Aravind, director of Aravind Eye Care, reasoned in a recent interview, “We realised that camps happen when we choose them to happen, not when the disease happens.”

They then set up several vision centres to reach out to a population of 50,000. Since the localised communities could not afford to appoint ophthalmologists, Aravind posted their own technicians to handle the centres. This gave them the idea of connecting the centres with the base using telemedicine technology from the University of California, Berkeley. They now have about 32 centres connected on a hubsand-spoke model to the base using broadband services available in the areas that they operate in. They have their own telemedicine software, for example, Adres for diabetic retinopathy and EyesTalk to maintain medical records. With these and other solutions, Aravind’s doctors sitting in a clinic in the town of Theni are able to treat a villager in Aandipatti, a tiny dot in the map, who seeks consultancy through a wireless videoconferencing facility.

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Last month, the Nanavati Hospital in Mumbai adopted eUNO R10—a mobile ECG application launched by Maestros Mediline Systems, a maker of high-tech medical equipment, in association with Vodafone. eUNO R10 enables cardiologists to monitor patients’ ECG reports on their BlackBerry smartphones. The instrument helps to diagnose and treat heart attacks almost immediately. Without such a mobile diagnosis, the symptoms of a heart attack could easily be mistaken for that of angina, which could turn out to be fatal.

More players in the field
Patho-India is an online community that has garnered over 2300 pathologists since its inception by Dr John Marshall Johnson in 1999. It has been working on tele-pathology at an academic level since then. Recently, it has launched Telepathology India—a telemedicine service that offers free tele-pathology consultancy. Pathologists can send in their slides for a second opinion, which are reviewed by an expert panel of pathologists.

Ahmedabad-based Medisoft Telemedicine offers a range of services including Tele Doctor, an integrated desktop telemedicine application; eHealthopinion, a Web-based telemedicine application; Medisoft Web conferencing, a suite of collaboration tools for education as well as joint consultation; and Medisoft mhealth, a mobile phone based telemedicine system.

eHealthopinion is a classic Web 2.0 application. It serves as a medium to connect patients with doctors as well as other experts across the world. Since its launch in 2007, 285 doctors and 100 hospitals from 46 countries have registered. Patients with a wide variety of problems ranging from minor throat pain to complicated neurological is-sues have registered their cases and received opinions from the respective experts.

Tele Doctor, a clinical telemedicine system, is their flagship product that is being used by clients in eleven countries including India, Pakistan, Cameroon, USA, Nepal, South Africa, France, Israel, Nigeria and Tanzania.

Founded by a Yale trained team, India’s first teleradiology company, Teleradiology Solutions, has been serving America and Singapore since 2002. It was the first Indian company to get accredited by the Ministry of Health of Singapore. Now, its services have extended to remote parts of India, such as the Ramakrishna Mission Hospital in Arunachal Pradesh, for whom it has been doing free reads on a daily basis since 2007.

Cisco HealthPresence
Cisco HealthPresence

Through its Telrad foundation, the company offers services of remote radiology reads to hospitals, especially those in interior regions of India, where correct and timely diagnosis can make a huge and often lifesaving difference. It assists in setting up the infrastructure to receive patients’ medical diagnostic images like X-rays, MRI scans, CT scans and ultrasound scans, over the Internet from hospitals all over the world. The aim is to use technology to take high-quality diagnostics to patients everywhere, especially in areas that do not have access to specialist radiologists.

Apollo Hospitals’ telemedicine wing recently collaborated with Cisco to implement its HealthPresence Extended Reach solution across mini clinics in several remote areas. They demonstrated, through a village near Raichur, Karnataka, how telemedicine can revolutionise healthcare in rural areas. Using the newly implemented solution, doctors do not even have to go to a telemedicine room to answer a patient’s request—they can simply attend to the patient using a laptop connected to the Internet. Detailed clinical examination, investigation, prescription and even a recording of the entire process are possible.

These are just a few randomly chosen examples. Several other institutions including Sankara Netralaya have full-fledged telemedicine services in operation in India.

Has telemedicine truly arrived in india?
Transcontinental robotic surgery is not happening every day, but it is clear that telemedicine has made a beginning in India. We have the know-how, the basic infrastructure and, more than anything else, a very strong business case for the same. However, without a doubt, challenges remain to be overcome before telemedicine becomes a widely-accepted model of medical diagnosis and treatment.

One of the major challenges, though the situation has improved since the early days of telemedicine in 2002-03, is the lack of reliable broad band connectivity in the last mile, especially in remote areas. Another is the unavailability of skilled manpower to manage the centres in rural areas. Plus, there is the issue of quality control and standardisation, in a relatively nascent technical space. And, though many might not agree, there is the issue of technology still being costly and a tad complicated for the masses. Finally, there is the perpetual issue of resistance to a computer acting as a ‘doctor’!

Several solutions are in sight. WiMAX, for example, could solve the last-mile con-nectivity issue. The mobile phone (with its high penetration) could mature to become an important tool in the telemedicine framework, thereby making the service available to a greater population. Organisations, such as the Indian Space Research Organisation (ISRO), are experimenting with VSAT-based connectivity for telemedicine services in remote areas.

Initiatives by the government could not only promote telemedicine but also help to ensure the quality and accountability of telemedicine-based services. The government of India was one of the earliest to take a step towards telemedicine. This is one reason why we find several start-ups working in this field.

“Way back in 2001, the government promoted telemedicine and supported pilot projects for concept testing. This initiative created awareness amongst industry players, and hence many companies have emerged. Later, they drafted recommended standards for telemedicine and healthcare. Those documents are very well-drafted and many national and international organisations are following them,” says Devendra Patel, director, Medisoft Telemedicine. Many state governments, including Himachal Pradesh and Gujarat, are also in various stages of the experimentation and learning curve. In short, there is a lot of hope in sight.

Broadband over Power Lines

Patel adds, “India is well-positioned in telemedicine markets world wide. It holds a very strong position especially in clinical telemedicine, which connects two or more clinics; the other aspect of telemedicine is home healthcare. Our Pakistani client always wonders why there are only two companies in Pakistan, whereas India has more than 15 companies in telemedicine. This is because of systematic efforts by government departments like the Ministry of Information Technology and organisations like ISRO. Due to their early initiative, companies like Medisoft found an opportunity in this segment.”

Initially, start-ups in telemedicine were merely seen as social innovators and people with a faraway dream. Sceptics doubted (and continue to doubt) the profitability of such ventures. However, it has now become obvious that there is a very strong business case for telemedicine, and these start-ups, if done right, will soon strike gold. Not just in India, but even in developed nations like the USA, the escalating costs of healthcare are driving the state governments to promote telemedicine.

Over the last year, we have seen not only more start-ups coming up in this space but also several technology majors including Cisco and IBM collaborating with governments and healthcare institutions to take telemedicine-related technologies (medical equipment, connectivity, data analysis, archiving, videoconferencing, et al) forward to the mainstream, not only in rural areas where skilled medical practitioners are rare but also in urban areas where the never-ending trafficjam makes it difficult for patients to reach the hospital in time.

As the population of stake holders in telemedicine rises, so does the quality of technologies and services. Dr Johnson points out that developments with regard to Internet penetration and bandwidth, videoconferencing and the digitisation of medical devices continue to give telemedicine a boost. Let us look at some of these developments to get a better picture of the telemedicine today.

Tele-consultation between geographically-separated doctor and patient using ReMeDi
Tele-consultation between geographically-separated doctor and patient using ReMeDi

From e-health to m-health
While the Internet is widely considered to be the backbone of the telemedicine framework, recent trends seem to be favouring mobile networks instead!

Mobile-to-mobile (M2M) connectivity is believed to be especially useful for health monitoring of the aged or chronically-ill patients at home. Dr Arjun Kalyanpur, chief radiologist and CEO, Teleradiology Solutions, points out that home health monitoring is a very important aspect of telemedicine. “Based on various research figures, it is clear that technology that allows for home monitoring of elderly and chronically-ill patients, coupled with telemedicine, will be a critical tool in preventing unnecessary hospital admissions and keeping healthcare costs down overall,” he says. And, this target population is more likely to have a mobile phone than an Internet connection. This is true in rural areas also, where the mobile network is more pervasive than the Internet.

At the simplest level, consider a healthcare professional who delivers prescriptions via SMS, as well as reminders to take the medicines on time. Or, consider medical equipment connected to the mobile network, such as the service from Maestros and BlackBerry along with Vodafone. On a more complex level, it is possible to use sensors or wearable micro devices on or around the body. Robert Miller, executive director of technology at AT&T, very appropriately called it ‘medical jewellery.’

These devices are powered by advanced signal processing and have sophisticated chip radios—they combine radio frequency (RF) capabilities along with processing and other required features. These can be connected through low-power Bluetooth or other technologies to a handset. Zigbee, a Wi-Fi like wireless solution, is being touted to be the ideal low-power local-area networking (LAN) solution for health monitoring solutions. The Continua Healthcare Alliance, an industry coalition working towards standards for telemedicine and health monitoring, also recommends Zigbee. It defines certain standards for the wide-area network (WAN) used for health monitoring, etc.

The handset could then transmit the sensor data to a central location, using a WAN, like a mobile network. This information would then be captured and interpreted by a server, to aid doctors in their treatment. This way, the doctors can get hold of a ‘trend’ rather than a mere ‘reading’ of the patient’s medical condition.

Telrad Foundation provides remote radiology reads for the Ramakrishna Mission hospital in Itanagar, Arunachal Pradesh
Telrad Foundation provides remote radiology reads for the Ramakrishna Mission hospital in Itanagar, Arunachal Pradesh

However, there is a lot of work to be done by the industry before such mobile-based health monitoring solutions become popular. First, they need to invest in finding ways to automate the flow of information and standardise the storage, transmission and viewing of information, in order to improve interoperability of the systems. Dr Kalyanpur adds that standards like HL7 (Health Level Seven) and DICOM (Digital Imaging and Communications in Medicine) hold a lot of promise.

Telepresence: putting minds together
Telepresence, long thought of as a high-end videoconferencing solution for corporates, is now turning into a telemedicine ally. Overall, it is proving to be more useful now since telepresence is now available as a ‘service’ from players such as Tata, and can be used without hefty initial investments.

Telepresence sessions prove to be very helpful in long-distance expert consultations. The consulting expert can not only view the patient’s medical records in great detail and high resolutions but also see and talk to the patient ‘in person.’ It instils more confidence in the patient, and helps the doctor diagnose and offer her opinions more confidently. Advanced telepresence systems also enable doctors to oversee or share opinions during complex surgeries.

More recently, foreign universities have started using telepresence for live demonstrations. Students can watch the surgery in great detail, just as if they are in the operation theatre. Yet, they would not be disturbing the surgeon at work.

Telepresence systems are even being used for advanced research where geographically-separated researchers would need to see experiments or diagrams as if they were next to each other. Research networks such as Internet2 are working with telepresence providers to create futuristic systems, which would provide researchers with an immersive environment such as medical clinic configuration or lab.

India Turning into R&D Powerhouse

However, the general opinion is that telepresence would be more useful if it could be set up in an ad-hoc fashion without too much advance notice to the service provider.

Health on the ‘cloud’
The highlight of a recent announcement by Verizon was the offering of telemedicine-based healthcare as a managed service, right from the equipment up to mobile integration and videoconferencing solutions. Apart from PC-based solutions, the company is also working with certain hospitals to provide specialist care using mobile-based videoconferencing. Such managed services would make it much easier and faster for hospitals to deploy telemedicine services to not just the urban population but even remote areas.

Medweb, a well-known telemedicine provider, has also started offering cloud services. The hosted solution is an alternative to costly, redundant infrastructure investments. The telemedicine cloud includes a 30-user licence covering one clinical specialty and two facilities or providers—one sending site and one receiving site—and provides HIPAA-compliant disaster recovery with three redundant copies of each patient record. Facilities can add additional clinical specialties as needed. A mini-clinic configuration is available for small sites or group practices. Medweb’s Web-based solution offers computer-based patient assessment protocols and integrates medical imaging, information management and security.

Such fully-managed telemedicine services are still a rarity in India, and provide a huge opportunity for start ups, as it would make it extremely easy for hospitals and other healthcare institutions to expand their reach. The market is likely to be extremely large, once the concept gains traction.

Portable and network-capable medical equipment
Telemedicine is not just about information technology and connectivity. It is also about the right medical equipment—portable, network-capable and robust instruments. A lot of work is happening towards that as well. The availability of extremely miniaturised and highly-capable lab-on-a-chip modules has indeed taken telemedicine forth significantly. The development of full-featured yet tiny medical equipment is a constant challenge posed by chipmakers like Intel to engineers during various embedded system design contests.

One recent example of such a device is the invention of the world’s smallest and lightest telemedicine microscope, announced in April. Aydogan Ozcan of the University of California, Los Angeles, unveiled details of his microscope in a paper published online in the journal Lab on a Chip. The instrument builds on an imaging technology developed by him, known as LUCAS (Lens-less Ultra-wide-field Cell Monitoring Array platform based on Shadow imaging). Instead of using a lens to magnify objects, LUCAS generates holographic images of micro particles or cells by employing a light emitting diode to illuminate the objects and a digital sensor array to capture their images.

Weighing 46 gm, the microscope is a self-contained imaging device. The only external attachment required is a USB connection to a smartphone, PDA or computer, which supplies the microscope with power and allows images to be uploaded for conversion into results that are then sent to a hospital. Samples are loaded using a small chip that can be filled with saliva or a blood smear for health monitoring. With blood smears, the lens-less microscope is capable of accurately identifying cells and particles, including red blood cells, white blood cells and platelets. The technology has the potential to help monitor diseases like malaria, HIV and tuberculosis.

The inventor believes that tools like the lens-less microscope could be digitally integrated as part of a telemedicine network that connects various mobile healthcare providers to a central lab or hospital, filling gaps in physical infrastructure with mobile tools. Transmission connections for such networks already exist in cellular networks, which have penetrated even the remotest corners of the globe. The microscope is also very cost-effective, allowing mass deployment even in third-world nations.

Robots in telemedicine
The Mayo Clinic, a well-known nonprofit healthcare institution in the US, has debuted ‘robot doctors’ this year. This ensures that patients in less densely-populated areas also have immediate access to stroke expertise and clot-busting medication necessary for treatment. When an emergency arises, the rural hospital places a call to an associated medical centre (or hub). The hub vascular neurologist is equipped with a telemedicine tool belt that includes a smart phone with a tele-radiology application and other technology such as a laptop with a Web camera. The remote, spoke hospital is equipped with a mobile robotic telemedicine camera system that is positioned near the patient’s bed. From afar, the stroke physician can observe and speak with the patient, and healthcare providers do a real-time consultation and review CT scans of the brain. If a stroke diagnosis is confirmed, appropriate treatment can be quickly administered, such as a clot-busting drug when a clot is blocking blood flow to the brain.

Similarly, the Frankfort Regional Medical Centre in Kentucky now relies on experts from the University of Louisville Hospital’s stroke centre. A robotic telemedicine machine placed in an examination room sees, hears and diagnoses patients, then suggests treatment.

Note that a robot in telemedicine does not have to be something hi-fi used to remotely control and perform surgeries. It could mean a simple computerised figure that sees, hears and speaks to patients, controlled by doctors through a network.

Even from this small sample of developments, it is obvious that telemedicine is an evolving technological space. Several improvements in the form of advanced, network-capable medical equipment, wireless communication technologies, mobile services, data acquisition, interpretation and archival systems, etc have given the field a boost. However, challenges and hence opportunities abound in India, to develop more user-friendly technologies, link up the last mile with reliable communication facilities, foster confidence amongst the people to go for telemedicine services and so on. With such a large population at the bottom of the pyramid without access to hospitals and, ironically, a well-matched population in the cities that is reluctant to go to the hospital even though there exists one, there is a business case strong enough for tech-makers to participate in the telemedicine revolution!

The author is a technically-qualified freelance writer, editor and hands-on mom based in Bengaluru