A recent report titled ‘Foreseeing the Future of Healthcare’ by Wipro and Dun & Bradstreet India revealed that while 70 per cent of India’s population resides in rural areas, only one-fourth of the country’s specialist physicians live in semi-urban areas, and even less than 5 per cent of them reside in rural areas. In the present scenario, remote delivery of medical advice along with diagnostic and healthcare services seems to be the best way to treat people living in villages. Here we are not talking about robot-doctors and tricorders but practical, low-bandwidth telemedicine and health monitoring technologies that will help the masses in India.
“On an average, India has one doctor for every 1700 people, while the optimal average should be one doctor for every 600 citizens. In some cases, the ratio is up to one doctor for every 25,000 citizens. The United States has one doctor for every 350 citizens, and if India aspires to become a superpower, it needs to increase the number of doctors by six times. This is impossible as no country can organically grow their medical population six times quickly and meet the quality. This is where telemedicine technology comes in the picture,” says Vishal Gupta, vice president-Global Healthcare Solutions Unit, Cisco.
“Telemedicine can virtually deliver a doctor, specialist or super-specialist to a patient in a remote area through networking technology. In the case of Cisco’s technology, the interaction between them is through video using a vernacular language. The doctor can read and see all the vital tests that are done on a patient. The patient can interact with the doctor as if the doctor is present in the same room. Finally, the doctor can dispense a prescription or recommend a course of treatment that can be taken by the patient just as he would do in a real-life situation. This fundamentally balances out the doctor-citizen imbalance we see in India as well as the urban-rural divide in terms of resource availability,” he adds.
Telemedicine and health monitoring technologies have been around in India for over a decade, and have been growing slowly and steadily. However, in recent times, several factors have boosted the growth of this sector. First of all, developments in the field of electronics, especially micro-electromechanical systems (MEMS) and system-on-chip (SoC) technologies, have vastly improved the size, quality and precision of medical equipment. Wireless technologies have enabled remote delivery of services. Information technology, especially the cloud, has improved the ways in which medical information is shared, stored and processed. The mobile phone, its services and apps have brought telemedicine and health monitoring to the masses—literally. In fact, the use of the mobile for keeping track of vital signs, analysing information collected by medical equipment, communicating health status to doctors and receiving advice from them has expanded the scope of telemedicine and health monitoring.
From being used only for delivering medical services remotely to rural areas initially, these technologies are now also being used to provide better services to patients in hospitals, take care of specially-challenged or aged people, monitor foetal health and even improve the fitness level of people.
Let us take a look at the key components of telemedicine, as well as recent innovations and some promising technologies and products in this space.
There is a wide array of telemedicine and health monitoring equipment available today. Broadly, we can divide them into diagnostic and therapeutic equipment like electrocardiographs and pacemakers, imaging technologies like X-ray and magnetic resonance imaging (MRI), medical instruments like blood analysis systems and dialysis systems, patient monitoring and consumer products like remote monitoring tools, insulin pumps and heart-rate monitors, as well as wellness equipment like pedometers and cardio trainers.
Such equipment can be thought of as having a layer of information and communication technology (ICT) atop a medical device. These usually comprise a combination of sensors, MEMS, low-power high-performance microcontrollers, wireless modules, signal conditioners, analogue-to-digital converters, etc, which work alongside user-friendly but powerful software. The infrastructure required includes uninterruptible power supply and Internet—both of which are a challenge in the Indian landscape.
“With increasing penetration of mobile infrastructure into the remote areas, mobility is expected to play a larger role in healthcare as well. Solutions will have to be designed to be mobile, as we go along. 3.5G and 4G are going to have a huge impact on the ability to deliver healthcare at the patients’ doorsteps. However, until the connectivity reaches rural areas, the impact will be seen only on the urban population and the changes will miss the vast majority of the population that lives in the rural areas,” remarks Rajeev Kumar, founder director, Neurosynaptic Communications—a company that has made a mark in the Indian telemedicine arena with its ReMeDi solution.
“Availability of electricity is also a huge challenge in rural as well as semi-urban areas. Alternatives like solar are still too expensive, although the prices are coming down. Plus, operation, maintenance and support of the telemedicine infrastructure are always a problem in the absence of adequately trained personnel,” he adds.
These challenges reflect in the design and engineering goals of telemedicine and health monitoring equipment.
Design considerations and constraints
According to Kumar, when developing telemedicine solutions, engineers should keep in mind data accuracy, patient safety, low power consumption, ease of use and ruggedness. At the same time, these solutions have to be very powerful and accurate.
Software engineers also have to consider the rural environment when developing applications for remote healthcare. The software has to be light, capable of running on minimal resources. Considering the fact that it might be used by untrained professionals, the interface must be very simple. It must also support local languages.
ReMeDi telemedicine setup is used in the remotest rural areas for conducting different types of medical tests
Gupta adds, “While implementing ICT-based solutions, especially in rural areas of India, the designers will have to keep in mind that the infrastructure available is at the bare minimum. The solution should be capable of adapting to this infrastructural deficit and work its way around enabling the healthcare services on the lowest possible bandwidth with minimal resources. Thus, while solutions in the West might work on 5 MB, in India they need to work at 500 kB or lesser. Cisco’s HealthPresence 2.5, for instance, can work even at 300 kbps.”
He further says, “The second design consideration is the language support. Cisco’s solutions work around this using a special queuing technology that enables patients to find doctors who speak their language and have the right specialisation.”
“The third design consideration in emerging countries is that patients sometimes want an unscheduled visit; we could call it ad hoc consultations. Cisco caters to these using scheduling systems, and also by bringing in ‘presence’ within the application to enable paramedics to find any doctor who may be available,” Gupta stated.
In the race to overcome these constraints and come up with the best and most cost-efficient solution, the industry has absorbed several interesting technologies from the world of electronics and telecommunications. While some solutions are characterised by advanced technologies, others focus on understanding and catering to rural India.
Let us look at some of the telemedicine and health monitoring solutions being used in India, and what makes them successful.
High-tech in small packages
The extensive use of MEMS is one of the greatest developments in the field of telemedicine and health monitoring in the last few years.
“MEMS is the technology behind various types of silicon sensors and nano-pumps. STMicroelectronics provides consumer sensor technologies that include multiple-axis motion and orientation sensors, compass, pressure, temperature, sound (microphone) as well as biological and molecular compounds. These sensors can now be applied to monitor various aspects of the human anatomy and organ functions where accuracy and sensitivity are critical,” says Vivek Sharma, regional vice president, Greater China and South Asia Region-India Operations, and director-India Design Centres, STMicroelectronics. ST adds these capabilities to its low-power microcontroller and communication chip technologies, and offers several innovative healthcare products.
ST’s Body Gateway (BG), an integrated remote monitoring solution for advanced telemedicine platforms, is an interesting example. It is a lightweight and low-power electronic system for measurement and management of physiological parameters like electro-cardiogram (ECG), heart rate, breathing rate, weight, etc. A tiny module that can be taped to the patient’s chest, the BG collects data from a suite of sensors, performs initial processing, stores the data and prepares it for transmission over a network to the remote application server.
Another interesting solution is the eye pressure monitor to monitor Glaucoma. Developed by ST in collaboration with Sensimed, the solution is based on a smart contact lens that uses a tiny embedded strain gauge to monitor the curvature of the eye over an extended period of time, providing valuable disease management data that is not currently obtainable using conventional ophthalmic tests.
Switzerland-based Debiotech and ST have developed silicon-based microfluidic devices that deliver insulin using a miniature disposable insulin pump. Insulin pump therapy is emerging as an attractive alternative to individual insulin injections. The patient is connected to a programmable pump including a storage reservoir, from which insulin is infused into the tissue under the skin, day and night, according to the specific needs of the patient. The system uses miniature MEMS-based technology, and also supports remote administration.
VereMTB is a multiplexed molecular diagnostic lab-on-chip that can identify the specific mycobacterium causing the infection and drug resistance in less than three hours from natural samples. It eliminates the need for culturing—the most time-consuming part of the traditional method. Additionally, due to its compact size, the system can be deployed in a wide range of settings at the point-of-need.
“The remote monitoring solutions from ST are based on the most innovative MEMS devices and detect even the slightest physiological movements. These signals are, in turn, processed by an internal microcontroller, and sent via Bluetooth, Zigbee, Internet, GSM or local network to a control station for monitoring, diagnosis and urgent life-support therapy,” says Sharma.
ST’s health monitoring solutions use a range of ultra-low power microcontrollers (the STM32L and STM8L series) based on a proprietary 130nm ultra-low-leakage process technology, which decreases overall energy consumption without compromising on speed and functionality. The company also has the required technologies for both short-distance (monitoring-device-to-recording device) communication as well as longer-distance (device-to-hospital) communication. Steady communication is enabled through its STM32W wireless network line of microcontrollers as well as its Bluetooth, NFC, Smartcard and RFID solutions. Their hybrid dual-interface EEPROM is used for data logging.
Keeping safety in mind
When developing health monitoring solutions, one should remember that it is more often than not used by people with special health constraints or conditions. Hence the solution itself must be non-intrusive and harmless without adding to their strain or causing new complications.
The non-intrusive, cloud-based pregnancy monitoring solution offered by Wipro Healthcare is an interesting example. The solution, piloted in hospitals in Bengaluru and Delhi, has been deployed in collaboration with a UK-based start-up, which provides the device for measuring foetal heart rate, maternal heart rate and other vital signs. Wipro provides the embedded systems solutions along with storage and analytics technologies on mobile and cloud platforms.
The technology, based on the principle of ECG, is so sophisticated that it can detect and interpret even the faintest heartbeat of the foetus. The wearable device is small in size as against an ultrasound device, which is large and uncomfortable, especially for women in the last trimester. The technology is also non-intrusive for the foetus and there are no transmissions to the womb as like in the case of ultrasound devices. It accurately records maternal and foetal heart rate, and uterine activity, thereby providing information on foetal and maternal well-being. The device is suited for both antenatal care, and during active labour and delivery. The comprehensive solution helps gynaecologists to monitor patients 24/7 using information delivered to their mobile.
This as well as Wipro’s cardiac care solution are based on the Wipro AssureHealth platform, which leverages Microsoft’s cloud, mobility and analytics offerings to allow care providers to monitor patients regularly and precisely. This is done through hosted services and mobile apps that integrate medical devices, IT Infrastructure and 24×7 customer support, to deliver highly-scalable solutions.
Managing diversity and individual choices
When we speak of healthcare in a country, there is a lot of diversity. There is diversity in needs, culture, infrastructure and usage. So a telemedicine platform has to be able to encompass all of these smoothly.
“Cisco HealthPresence 2.5 gives a lot of choices to our customers. Our vision is to allow healthcare collaboration across any standard video endpoint, and Cisco provides almost ten choices from low-end desktop based to mid-end Tandberg-based to high-end truly-immersive-based video endpoints. In addition to high-quality audio and video, we believe in integrating with all the relevant medical devices and giving lots of choices to our customers based on standards-based medical device integration. We also want to make it very efficient for the doctors to do the consultation. So we have enabled integration with any EMR the customer may have, as well as integration with any kind of imaging modalities,” says Gupta.
The Cisco healthcare solution leverages the network as a platform, and combines advanced audio, video and third-party medical devices to create a high-quality clinical consultation environment enabling doctor-patient consultation remotely. Primary healthcare centres or community healthcare centres in rural areas are connected to the district hospital or a super-speciality hospital that hosts the healthcare solution. The process starts with a patient visiting a village healthcare centre where the point-of-diagnosis (PoD) is installed. Thereafter, the local paramedic initiates a call with the specialist, who consults as if they were face-to-face, and gives a prescription.
“While the platform can perform well from about 256 kbps, to get the optimal user experience, we recommend about 1 Mbps. The whole interaction is managed out of a cloud with some specialised software at the edge,” adds Gupta.
The medical solution has been implemented in seven districts (Raichur, Shimoga, Chitradurga, Gwalior, Sehore, Datia and Chindwara) in partnership with the state governments of Karnataka and Madhya Pradesh. As of December 2012, they had conducted 27,000 speciality and super-speciality consultations in just one year.
“Our aim is to provide healthcare solutions to the rural population in a manner that eliminates the need to travel long distances to obtain basic healthcare facilities. Our solutions are being successfully implemented and we have contributed to the reduction in maternal mortality and infant mortality rates. Women and children form over half of the patients who use the system. We have used the same infrastructure to educate pregnant women on what to expect when expecting,” says Gupta.
Understanding rural India
ReMeDi is one of the oldest telemedicine solutions, made for India, in India. It has around 700 village centres, each one located at a population of 5000 or less, in the most rural areas. More than 200,000 consultations have been carried out in the last couple of years, where patients have actually paid for the consultations.
The ReMeDi medical data acquisition unit and ReMeDi software can measure basic physiological parameters of the patient and provide vital information to a doctor for preliminary diagnosis. Video conferencing integrated into this solution works even at a bandwidth as low as 32 kbps. With both the capital and operational expenses reduced, it is an extremely cost-effective solution for telemedicine applications. After a minimal amount of training, the solution can be used by anybody who is familiar with the usage of computers.
“ReMeDi facilitates the basic diagnosis of a patient remotely by a doctor by enabling the real-time measurement of the patient’s ECG, temperature, oxygen saturation and blood pressure, as well as real-time transmission of auscultation sounds of the patient, captured using the electronic stethoscope. A preliminary diagnosis of cardio-vascular problems can be carried out using stethoscope, ECG and BP measurement. Using high-resolution images taken from a normal Web camera, doctors can provide eye care, dermatology and ENT services,” says Rajeev Kumar.
Multiple consultations can take place simultaneously, with the server performing the task of session management. All the medical data is stored in the electronic medical records of patients on the central server and is available on-demand. Both real-time as well as store-and-forward modes of data transfer are supported. The client-server architecture also enables various other entities (pharmacies, clinics, diagnostic labs, etc) to be part of the network. It allows associated services to be offered to the consumers through this network.
The solution features customised billing, customer feedback, offline audits, etc. It is rugged, designed for rural conditions, and is very easy to use. It is completely isolated from external power supply, and is suitable for any kind of IP connectivity. It has a low-bandwidth requirement (32 kbps) for real-time audio, video and medical data transfer. In all, it is designed perfectly for Indian usage conditions.
Providing healthcare where it matters the most
In areas like Kargil or remote villages in Andaman & Nicobar, where there are no communication links, providing healthcare would require not just technology but also infrastructure.
The Indian Space Research Organisation’s (ISRO) telemedicine pilot project was started in 2001, to overcome precisely this problem—and they have done it quite successfully. The initiative involves several system providers including Infinium, Apollo, OTRI, BEL-VEPRO and TeleVital, and connects remote health centres with city-based super speciality hospitals using INSAT satellites.
The telemedicine system consists of customised hardware and software at both the patient’s and doctor’s end, and diagnostic equipment such as ECG, X-ray and pathology microscope/camera at the patient’s end. All this is connected using a very small aperture terminal (VSAT) system and controlled by ISRO’s network hub station. A telemedicine system consisting of simple computers and communication systems conveys the medical images and other patient-related information to the specialist doctors—either in advance or on a real-time basis through the satellite link—in the form of digital data packets. These packets are received at the specialist centre, where the images and other information are reconstructed so that the specialist doctor can study the data, diagnose, interact with the patient and suggest appropriate treatment during a video conference with the patient.
Presently, ISRO’s telemedicine network has enabled 306 remote centres and 16 mobile telemedicine units to be connected to 60 super-speciality hospitals in major cities. About 150,000 patients are being treated every year.
“It is a myth that establishing a telemedicine platform is expensive and a challenge. We have been able to demonstrate that the platform costs can be brought down to less than a dollar per consultation. The basic requirement for setting up the system is hardware, software and a telecommunication link. Also, there is a significant reduction in the prices of these basic requirements, making them well within the reach of most hospitals. The expenses may even be recovered by nominal charges to the patients, which would be much less than the physical travelling costs incurred,” comments Gupta.
“The need of the hour is standardisation of telemedicine practices and communication hardware protocol in the country,” he adds.
The author is a technically-qualified freelance writer, editor and hands-on mom based in Chennai