Telemedicine Extending Quality Health Care to Rural Population.

1. Telemedicine Extending Quality Health Care to Rural Population. Prof. Jayanta Mukhopadhay Dept. of Computer Science & Engineering. IIT Kharagpur.

2. Two Contradictory Facts • A rural hospital in Hingelgange, North 24 Parganas, West Bengal, was almost without any doctor since its inception (1997). • IMA opposed introduction of new medical colleges in West Bengal, as many doctors did not have employment. Reported around 2004

3. Qualified Consulting Doctors. Total No. of Doctors: ~ 5 lakhs.

4. Population Distribution Total Population: ~ 1 billion.

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

6. Health Professional Statistics

7. Public Private Hospitals: 131 76 Health Centers: 1269 0 Tertiary Center District Hospital State General Hospital Subdivisional Hospital PHC Subcenters Subcenters Subcenters Subcenters Health Infrastructure in West Bengal.

8. Which gets priorities in planning? • Lack of infrastructure. • Non-utilization of infrastructure. • Wastage of resources.

9. Providing medical information and services from distant locations. Evolution of Telemedicine - Through postal system Using Telephone Using computers Telephone Line Telemedicine

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

11. Information exchange between Hospitals and Physicians. • Networking of group of hospitals, research centers. • Linking rural health clinics to a central hospital. • Videoconferencing between a patient and doctor, among members of healthcare teams. • Training of healthcare professionals in widely distributed or remote clinical settings. • Instant access to medical knowledgebase, technical papers etc. Applications in different forms

12. Improved Access Covers previously unserved or underserved areas. • Improved quality of care Enhanced decision making through collaborative efforts. • Reduced isolation of healthcare professionals Peer and professional contacts for patient consultations and continuing education. • Reduced costs Decreased necessity for travel and optimum uses of resources. Benefits of Telemedicine

13. Why it is relevant to our society Poor infrastructure Non-availability of experts (disparate distribution) Low doctor-patient ratio (large population) Lack of proper medical education Special attention required for Public Health Care System

14. Major Challenges • Poor Data Communication Infrastructure. • A Large Population Catered by Government Hospitals. • System Features should be scalable. • Cost of the system should be scalable.

15. PHC Subcenter PHC SHC PHC THC SHC THC THC THC • How telemedicine could be effective? • Which form of telemedicine is most appropriate? • How our medical professionals would be motivated? Different Strategies

16. What travels to a village? • Technology. • Human Expertise. • Training & education.

17. Medical Instrumentation Sensing Bio-medical Signals, Medical Imaging, Measurement of Physical Parameters e.g. Body Temperature, Pressure etc. • Telecommunication Technology Trans-receiver on different communication channels and network such as, on wired network, wireless medium etc. • Information Technology Information representation, storage, retrieval, processing, and presentation. Technologies Involved

18. Telemedicine: An Overview • Availability of medical information at remote end. • Discussion on the patient case. • No patient transfer. Local Health Centre Communication Channel • Service Modalities • Store and Forward • Real-time / Online Telemedicine • Mixed Mode • Mobile telemedicine / 3G Medicine • Web based Telemedicine Remote Health Center

19. Telemedicine: Using ICT Video Conference Modem Telephone Referral Hospital Microscope and other medical instruments Video Conference PSTN/ISDN/VSAT link Digital camera Scanner Telephone Printer Modem Nodal Hospital • Modern Telemedicine systems are developed on Electronic Health Record (EHR) systems.

20. 512 Kbps Leased Line State Switching Centre Referral Centre 512 Kbps Leased Line District Switching Centre Nodal Hospital Schematic Diagram for Telemedicine using Leased Line 2 Mbps Optical Link

21. Video and Data Conferencing Doctor Patient

22. If required concerned data may be resent to remote hospital Multi-Reference in Tele-consultation A center acting as local asks for tele-consultation with a remote center which can again be able to consult with another remote center. Attending local doctor Remote Hospital 1 Remote Hospital 2 Local Hospital Patient

23. step2. Download Information Step 1. Upload Information Telemedicine over web Telemedicine Server Internet Step 4. Receive Suggestion Step 3. Post Suggestions Referral Hospital Patient Console

24. Use of Mobile Devices in Telemedicine

25. ALR14:12 Attend Cardiac Patient Pri = Hi B.P. Increased Loc = Male Ward Room-102,Bed-14 BP =180/140 Tmp = 98 Pulse = 95 Hemoglobin = 8.3 Dead Line = 20Minuts ALR20:10 Attend a trauma pat in emerg. Pri = Hi. Unconscious. External Bleeding Dead Line = 10 M. Age = 30Y Sex = M. RR = 24 BP = 100/190 Pulse = 120 . Emergency Messaging Emergency message for attending a patient admitted in hospital. Emergency Message for attending a patient of accidental emergency.

26. Voice • Image • Video • Graphics • Elements of Medical Records • Commands to a surgical robot Exchange of Information at a Distance

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

28. TelemediK TelemediK V1.0, V2.0, V3.3, V2004, V2005 A peer to peer application. Facilitates specific care for different diseases such as dermatology, hematology, orthopedics, pediatrics, oncology, cardiology etc. Online graphics communicator Peer to peer discussion Annotation of patient images and profile images. Text chatting Telemedicine Systems: Developed at IIT Kharagpur

29. Based on peer-to-peer network topology. Physical transmission of patient medical records. Symmetry in tele-reference. TelemediK Model • Limitations: • Duplication of records incurs • increased storage cost. • May violate data consistency. • High bandwidth requirement.

30. iMediK iMedik V2007, V2008, V2009. Client interfaces are mostly provided through internet browsers. Supporting care of same set of diseases as handled by TelemediK. Additional Diseases like HIV Pediatrics and Drug resistant tuberculosis. Online graphics communicator Conference among multiple participating doctors. Web based telemedicine system

31. Based on the Central server model. Usually deployed at in the public network like WWW. iMedik Model • Limitations • No physical separation of records. • Needs higher configuration. • Security threats prevail. • Less or no fault tolerance. • Requires uninterrupted connection to external links. Four Layer Architecture

32. iMedik-D (Under development) Referral Activities through a Central Server. Hybrid Model: For some in-house patient management through the Central Server. Hierarchical Distributed system (without any Central server.) Distributed Telemedicine System

33. Two types of nodes - main sever and peripheral server. Multiple peripheral servers connected to one main server. Deployment of hospital EHRs at peripheral servers. Symmetric patient referral Data segregation partially achieved. iMedikD Symmetric: Server Model

34. Combination of centralized server model and distributed server model. Supports both the scenarios Organization that can not afford the cost of a PS. Example – H2 Organization that can bear the cost of additional PS. Example – H1, H3 iMedikD Model: Hybrid Server Model

35. No central or main server. Tele-consultation is carried out in the origin server. Hierarchy of reference. Each hospital hosts a separate EHR system. Can be deployed in the public domain. iMedikD Hierarchical: Server Model

36. iMedikD Hierarchical: System Architecture • A few additional services: • Manage telemedicine network • Refer a patient. • Fetch doctors information. • Only reference to data is sent with temporary log in information: • Securely. • Transparently.

37. Client interfaces for PDA and mobile phone. SMS based Emergency messaging system. Developing instruments with mobile interfaces. Mobile Healthcare

38. Multi-tier secure telemedicine system. Focuses on service oriented approach. Facilitates health care services through Internet. Salient features Encompasses all the features of TelemediK. Completely browser based interface. Complies with HIPAA security standard EPR standard proposed by National Task Force for Telemedicine Standards, MCIT. Features of iMedik

39. Summary of Patient Records

40. Visit wise patient record display

41. Patient record browsing

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

43. Growth Chart This graph plots Age vs. BMI. The red line indicates the patient’s BMI. Other 3 lines indicate reference of WHO standard.

44. Diagnosis

45. Decision support in prescription

46. Deployment of Telemedicine - Tripura TelemediK 2005 deployed in 11 hospitals – • 2 Referral Hospital in Kolkata • 9 Nodal Hospital in different districts.

47. Deployment of Telemedicine – West Bengal TelemediK 2005 deployed in 20 hospitals – • 6 Referral Hospital in Kolkata • 14 Nodal Hospital in different districts. iMediK installed in Calcutta Medical College in July 2009.

48. Telemedicine being increasingly used for providing health care services. Effective and efficient in managing resources and time for delivery of health care. Telemedicine systems are evolving: Peer to peer ► Centralized Server based ► Distributed Systems. Looking for a great healthy future of our public health care system in our country. Conclusion