- Email: [email protected]
Telemedicine and cardiology—decade of our experience
Telemedicine and cardiology—decade of our experience
life-like images and live ones too. After NASA used it efficiently for their staff, telemedicine was still elusive. With the growing aging population and physical disabilities, the medical industry realized that the same concept can be used for the elderly and the disabled. The whole idea behind the concept is to deliver medical help to a person where it is not possible to reach them immediately. For an elderly, a space station or their home has an equal value because they cannot reach out for medical help even if they want to.
P Krishnam Raju, MD DM* SG Prasad, BE MS**
TELEMEDICINE—NEED IN INDIA
ABSTRACT Information and communication technology (ICT) has enabled telemedicine to become an effective model for healthcare delivery. Patients have been networked irrespective of their location for remote monitoring and timely diagnosis with this technology. This article elaborates on our telemedicine experiences, methodologies adopted and highlights the various design aspects to be considered for making telemedicine effective. An important aspect that emerged from our study was that this technology can be utilized as an excellent screening tool for patients at remote centers and undertake preventive measures for potential patients at risk of cardiovascular disease.
The idea of performing medical examinations and evaluations through the telecommunication network is not new. Shortly after the invention of the telephone, attempts were made to transmit heart and lung sounds to a trained expert who could assess the state of the organs. This started as early as in 1906.2 India is a nation of 1.3 billion people populating a subcontinent sparsely in pristine landscapes or in a startling density in some of the world’s largest cities. In today’s world, with several advancements made in the medical field, still the benefits are available to the privileged few, residing mainly in the urban areas. India with its vast population of which 70% are poor and live in difficult to reach rural and inhospitable terrain find itself inaccessible to quality healthcare services. It must be noted that the average per capita spent on healthcare is 5.2% GDP, one of the lowest in the world and various healthcare indicators are also lower than the global average.2 The Government of India has been investing in telemedicine in a bid to make healthcare more accessible to the country’s rural communities. But skeptics are wary about the limitations of the technology when it comes to diagnosis, care, and surgery. This chapter here deals with the current scenario of telemedicine and cardiology in India, with special emphasis on telecardiology, while highlighting our own experiences over the last 1 decade. It primarily focuses on the requirements in terms of technology, communication, infrastructure, and human resources to ensure a practical workable model catering to the demands of our country.
Keywords Bandwidth, cardiology, CARE, HIPAA, ICT, PACS, telemedicine
INTRODUCTION In the last 4 or 5 years, telemedicine has generated immense interest among users and medical professionals. Telemedicine is actually a branch of science that has been based upon the use of telecommunications. Today, telecommunication has advanced gradually to a level where audio, video, and text are all possible at the same time. Simultaneously with the growth of telecommunication, even the telemedicine industry has been growing. However, telemedicine is not as new an industry as people think, and in fact, it has existed over 30 years in the medicine industry.1 National Aeronautics and Space Administration (NASA) had a big role to play in the popularity of telemedicine and they started using it when humans were being sent to space. When scientists were sent to space on space ships, their vital statistics and other health conditions were monitored through telemedicine. This development came in as early as 1960. However, after that communication industry has developed by leaps and bounds and today, complicated satellites are used for transmitting
Telemedicine—Definition ‘Telemedicine has been defined as the use of telecommunications to provide medical information and services’. The actual practice of telemedicine can be defined as integration of medical, communication, and information technology to provide medical advice on the basis of comprehensive information transferred from remote centers to specialty centers. If we were to talk from a layman’s point of view, we will not be absolutely wrong if a patient calls up a doctor on account of a headache and the doctor prescribes a medicine and define that as ‘telemedicine’. However, the issue that comes up with this is the fact that the transaction between the doctor and patient is not documented and this piece of information cannot be retrieved for any further reference. It is therefore imperative that we ensure that telemedicine services are used as judiciously as withdrawal of money from an ATM where everything is accounted.
*Consultant Cardiologist, Chairman, **Chief of Telemedicine, CARE Foundation, CARE Hospital, Road No. 1, Banjara Hills, Hyderabad – 500034, India. Correspondence: Dr. P Krishnam Raju, CARE Foundation, CARE Hospital, Road No. 1, Banjara Hills, Hyderabad – 500034, India. E-mail: [email protected]
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Burden in India—Coronary Heart Disease Mortality Statistics Specific mortality data ideal for making comparisons with other countries are not available in India. This is due to inadequate and inappropriate death certification, and multiple concurrent causes of death. The annual surveys conducted by the Registrar General of India cover about 0.5% of deaths in rural India. The figures published by the World Health Organization (WHO), drawn mainly from this source and for what they are worth, show a much higher prevalence in India than in many other developing countries. Diseases of the circulatory system are still one of the top 10 causes of death in rural India4 with comparable proportions of ischemic heart disease (IHD) and cerebrovascular disease comprising majority of deaths in this category. In another study conducted as a part of the Andhra Pradesh Rural Initiative (APRHI) in 20 villages (size 4535) it was observed that 13.2% of them suffered from diabetes, of which 6.4% were diagnosed and 6.8% undiagnosed. Also 15.5% of them were in the prediabetic stage5 (impaired glucose tolerance). Another study for the assessment of CVD and risk factors among 345 adults in rural India (APRHI) attributed 25.2% to smoking and 27% to hypertension.6 Even though the number of open-heart surgeries performed (42 operations per million) is small as compared to 1700 per million in the USA, it provides a clue to the enormous demand in India. There are approximately only 500 fully operational cardiac centers in India with surgical facilities. Clinical impression alone suggests that there has been phenomenal increase in IHD throughout India. As in other developing countries, the reasons are obvious. Increase in life expectancy (from 41 in 1961 to 65 for male and 67 for female in 2010), smoking, western-style diet (with increase in saturated fat, salt, calories, and less intake of fiber), and decreased physical activity resulting in obesity are all responsible. Urbanization and industrialization are on the increase and responsible for many of these changes in lifestyle.
Table 1 Health statistics. Population deprived of healthcare services Specialist healthcare providers in urban areas Allopathic doctors available per 1000 of population Doctors available per 1000 of urban population Doctors available per 1000 of rural population Relative cost of setting a 100 bed primary care hospital to a tertiary care superspecialty hospital Spend on healthcare as a % of GDP Government spend on healthcare as a % of GDP
>700 million 70% 0.6 2.97 0.50 1/10 5.2 0.9
GDP: gross domestic product.
Unlike our professionals in the West, where telemedicine is more often used as a ‘second opinion tool’, the lack of medical expertize or specialists even 100 Km away from cities, suggests that we often need telemedicine services to ensure that patients living here get their first opinion. So the whole perspective of the process of telemedicine in India is distinctly different from the West. Telemedicine—Actual Need of this Service Indian healthcare is very city centric and most of the healthcare services are highly skewed in favor of urban population, which is 28% of the Indian population. Table 1 highlights some of the details2 to corroborate this fact. Healthcare today involves multiple work centers and interdisciplinary work co-operation. In addition to this the increasing mobility of people and the actual time span between health episodes for patients have made it increasingly difficult for facilitating timely diagnosis. Moreover the lack of adequate infrastructure at district/rural hospitals and the unwillingness of people to travel to cities either due to lack of time/monetary constraints have left us with no choice but to evolve systems in a manner that quality healthcare services can be delivered with the use of the information and communication technology (ICT) platform. Telemedicine finds its application in various disciplines—the most notable being in radiology, cardiology, pathology, dermatology, and opthalmology.3
Risk Factors—Old and New The traditional risk factors such as smoking, high blood pressure (BP), high serum cholesterol level and diabetes are applicable to the majority of cases in India. The emerging risk factors— abdominal obesity, high triglycerides, insulin resistance, the so-called metabolic syndrome, elevated homocysteine levels, fibrinogen factors, etc.—need not be invoked to explain the present high incidence of heart attacks as they are yet to be proven conclusively as being causative in this era of evidencebased medicine. Control of the traditional risk factors and use of proven preventive strategies should suffice in any preventive program. Keeping all of the above in mind it has become imperative that secondary and primary healthcare infrastructures now have to be empowered by making available the expertize from these tertiary level centers located in the urban areas. This is where ‘telemedicine’ plays a very significant role. The greatest impact of telemedicine is on the patient, the family, and the community. Using telemedicine technologies reduces travel time and related stresses to the patient. In many
Need for Telemedicine in Cardiology Among the many health predictions for the new millennium, the most alarming is that of cardiovascular disease (CVD)— heart disease and stroke—topping the list for death and disability. While there are undoubted regional differences between the developed countries and other economies, the predictions for India by 2015 show a steady increase since 1985. The projected rate per 100,000 for 1985 for all ‘circulatory diseases’ was 145 males, 126 females; for 2000, 253 males and 204 females and for 2015, 295 males and 239 females, which is higher than that for other causes such as cancer. In a mortality surveillance study that was conducted in 45 villages (population 180,162) during the period 2003–2004 showed that 32.6% of all deaths were due to diseases of the cardiovascular system, of which 34.3% were males and 30.2% females.4 JICC Vol 2 Issue 1
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instances, patient movement would require travel by additional family members, day care costs, and time away from the job. This disruption in the local community can be avoided when proper technologies are used to bring the consulting specialist to the patient. Our experience with the district hospital Mahbubnagar7 revealed a cost saving of 73% because of providing echocardiography (ECHO) consultation through telemedicine.
Table 2 Categories of medical information. Basic categories
Textual data Images Audio and video
Activity categories
Clinical consults Doctor–patient interaction Education and administration
Factors that Drive Telemedicine • Need to decrease costs of day care through increased efficiency and decreased provider time in travel. • Detect disease early. • Need to increase access to care for underserved populations, which cover the war theatre zone, people living in inaccessible terrain and also natural disaster struck areas. • Convenience to patients, and facilitate follow-up care. • Desire to address new markets or new patient populations. • Local capacity building of healthcare workers. • Obtain epidemiological database to understand disease pattern across country. Telemedicine as a Process Telemedicine essentially involves the integration of three technologies: • Medical equipment (medical technology). • Electronic patient records and clinical data (information technology). • Mode of communication (communication technology).
C-Band dish
Medical Technology This includes the medical equipment and the interfaces available in them to integrate them with computer systems. In earlier days, all medical manufacturers had their own proprietary formats, which meant that the images acquired in machines could be viewed only in the same systems. This raised issues of interoperability and consequently the American Board of Radiology and National Engineers Manufacturing Association (NEMA)8 suggested that all medical equipment follow a standardized format for imaging–Digital Imaging and Communication System (DICOM). This ensured that all medical equipment generate an output, which can be viewed in any of the medical systems, thereby solving the interoperability issue.
Figure 1 KU-Band dish.
analog signals, which may be transported on C-Band or KUBand. The transmission and receive frequencies available with the C-Band (Tx—6 GHz; Rx—4 GHz) are much less than the respective frequencies available with the KU-Band (Tx—14 GHz; Rx—11 GHz). Satellite transmission requires an up-link to the satellite and a down-link to the location. The KU-Band (Figure 1) satellite dish is relatively small and portable on a truck compared to the C-Band dish. However, the range and sturdiness achieved with static dishes compared to the mobile dish is much higher. The advantage with satellite transmissions is that they have no boundary restrictions. It allows transmission of large amounts of information. It is ideal for sending visual information to multiple locations. However, the disadvantage is the cost. It is
Information Technology: This includes the kind of computer systems that are required in terms of clients and servers. This varies from site-to-site based on the actual modalities integrated for telemedicine. The system architecture involves the operation and transfer of medical information in multiple categories that are defined in Table 2. Communication Technology The transmission mode may be transported via satellite or terrestrial media. Terrestrial modes include microwave, fiber-optic, and conditioned copper cables. Satellite transmission allows a full motion broadcast quality picture. Most satellites transmit JICC Vol 2 Issue 1
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approximately 8 times as expensive as terrestrial transmission. On the other hand, terrestrial transmission is less expensive to operate on an hourly basis but is limited to areas that are linked to the appropriate line. Video transmission normally requires a bandwidth (carrying capacity) of 90 million bits per second (Mbps). A telephone call requires 64,000 bits per second. The fastest speed available with current digital technology is 1.54 Mbps. This requires a bandwidth commonly referred to as T1. T1 consists of 24 voice channels, which may be combined with higher bandwidth as needed. The higher the bandwidth, the better the image quality, however, increased cost is the trade-off for better image quality. Fiber-optics is available from long distance and local telephone companies. Optical fibers consist of strands of hair-thin glass and uses light to transmit telecommunication signals. They may be leased as a dedicated line or on-demand basis. Optical-fiber has a wide bandwidth allowing for choices of transmission speed. Due to cost constraints, T1 line is not available in all areas. Today with the advent of broadband internet technology, accessibility at an affordable cost has become a reality and most applications are now based on web technology. One of the key parameters to be assessed as described above is the ‘bandwidth factor’, whenever we talk of communication. A simple equation which will help us in determining this is given below. Image resolution =
important to ensure that there is no compromise between video (of medical images) and audio (voice). Typical applications are echo, ultrasound, cath procedures. This would involve direct interaction between the expert–physician–patient at the time of the investigation. Consequently, a best practice is to have a prefixed scheduled time for this kind of methodology. Near Real Time This include application like electrocardiography (ECG) wherein there is an acquisition time involved for taking an ECG and then followed by transmission through the appropriate port. Store and Forward This typically is used for static images such as X-ray, computed tomography (CT) scan, magnetic resonance imaging (MRI). The advantage of this mode of communication is that one can archive all the images and then forward all the cases simultaneously, thereby reducing usage time of connectivity between locations.
APPLICATION SOFTWARE The software design should provide a unique patient identification numbers to archive records with necessary clinical information and retrieved at any point of time. The basic architecture (Figure 2) should comprise of: The application software should be designed keeping in mind perspectives of 5 users: • Patient—who would use the service • Primary health center (PHC)—which has trained medical personnel
Bandwidth × Cost Transmission time
Table 3 gives us an idea of bandwidth requirements for various applications.
METHODOLOGIES Real Time This typically includes transmission of dynamic images with minimum delay. The bandwidth for such applications is
User interface Image acquisition system
Table 3 Bandwith requirements. Modality Textual information Images transfer (like ECG, or jpg formats) Images (CT, MRI) DICOM format Echocardiography (live) Angiography Surgical Simple video-conferencing (for tele-consultation)
Backplane
Bandwidth (Kbps) 64 128 192 256 384 512 >1000 √ √ √
Processing
Communications
√√ √
√
Patient records
√√ √
Protocols
√√ √
Acquires images and data from the medical equipment Stores and retrieves patient data Secure, transfers data, allocates bandwidth Interacts with the system
√√
√√
Unites the serivce areas Performs specialized image manipulation
√: minimum requirement; √√: preferred requirement. CT: computed tomography; DICOM: digital imaging and communications in medicine; ECG: electrocardiography; MRI: magnetic resonance imaging.
Figure 2 Application software architecture.
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the privacy of patient health information. Further, lack of proper vigilance at remote settings attracts hostile intrusion from both hackers and virus. To fortify the telemedicine network against unauthorized access, some stringent security features in the network can be incorporated: • All the e-mail communications should be in encrypted form. The e-mail content is encrypted into strings of codes and transmitted over the network. At the receiving end, the coded message is assembled back into original form with help of a key. Even if someone manages to access it illegally during the course of transmission, the coded message will make no sense. • Facial recognition system helps the service providers to clearly identify the patients on the network, especially in the case of video-conferencing. • Digital identity card is provided to the remote patients after identity verification by authorities. The encryption features and digital signature of the patients in the card authenticates the users and allows them to access online health services. • The access to all the point-of-service computers should be user authenticated, to ensure that only authorized personnel access the system. • The computer network should be protected by firewall and should be constantly monitored to detect any intrusion. There should be an audit system, which maintains a record of time, frequency, and nature of the hostile attacks made on the network. The security features in the network enable the health service providers to provide quality healthcare services to remote patients in a safe and secure way. The patient health privacy is protected and this is in line with HIPAA compliance norms, thereby ensuring that telemedicine can safely deliver customized health solutions to remote communities.
• Expert center/specialist—involved in consultations • Medical administrator—who administers the network • Expert or doctor—who gives opinions and interacts with the patient. A good telemedicine system should be designed to achieve the following: Precise Definition It gives a graphical user interface, provides an immediate, selfexplanatory real time access to all the available data of a single individual patient as well as defined patient samples. It gives a precise description of the problem rather than part of the solution. Logical Processing This system creates an integrated patients record, own a central function in the hospital context, the integration of a knowledge base into this record, and to develop testing facilities for clinical data’s processing and for clinical support systems. It includes all patient related data, necessary administrative, and organizational data from all involved departments, and also some decision support from those departments. The Medical Record The patient record consists of modules of a database that are constructed according to logical integrated complexes: modules for demographic data, scheduling, subjective complaints and physical (SAP) findings exist: grouped data as the finding of a complex investigation or therapy exist as well as a problem list and a toll for the reimbursement. Downloading of parts of the patients record both textual and DICOM compatible images to intelligent terminals, where processing can be performed, and uploading of updated data are the main principles on the system.
Retrieval and Archival In medical imaging, electronic picture archiving and communication systems (PACS) have been developed in an attempt to provide economical storage, rapid retrieval of images, access to images acquired with multiple modalities, and simultaneous access at multiple sites.9 Digital medical images are typically stored locally on a PACS for retrieval. It is important that facilities have a means of recovering images in the event of an error or disaster. While each facility is different, the goal in image back-up is to make it automatic and as easy to administer as possible. The hope is that the copies won’t ever be needed but as with other disaster recovery and business continuity planning, they need to be available if needed. Ideally, copies of images should be streamed off-site as they are created. Depending on upload bandwidth and image volume, this may not be practical if the back-up system cannot be configured to tune bandwidth usage and frequency of back-ups. Other options include removable media (hard drives, DVDs or other media that can hold many patients’ images) that is physically transferred offsite. The content of these copies must be protected via encryption from exposure to unauthorized personnel or stiff penalties
Clinical Workstations A cornerstone of this system is a problem list with a distinction between active and inactive problems. The system uses relational database technology. The system is one of the models of medical records, which supports the medical user in the most advanced way with a maximum amount of structured information in relation to the actual processed data of the individual patients. Security Since information is exchanged over a great distance, through a series of local and wireless networks, the remote settings of the patients make the exchange of health information with health providers highly vulnerable to hostile intrusion. The Health Insurance Portability and Accountability Act (HIPAA) compliance norms makes it mandatory for all the covered entities like hospitals, clinics, clearing-houses, physicians, medical insurance companies, and other health service providers to employ secure computer network systems, which follow stringent security codes. The nomadic or remote settings of the patients make it a challenging task for the health providers to maintain JICC Vol 2 Issue 1
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having rheumatic heart disease (RHD), 139 patients (11%) as having congenital heart disease (CHD), 245 patients (21%) as having coronary artery disease (CAD), 138 patients (11%) as having nonrheumatic valvular heart disease (VHD), 173 patients (14%) as having hypertensive heart disease (HHD), 151 patients (13%) as having cardiomyopathy (CMP), 41 patients (3%) as having pulmonary arterial hypertension (PAH), 24 patients (1%) as having pericardial disease (PD), and 4 patients (0.3%) were diagnosed with cardiac masses. Percentage mentioned for all the abnormal cases refer to a cumulative count as a patient could have had more than 1 disease condition. Free cases and white card (WC) patient were poor and/or below poverty line patients who were charged nominal rates, as against nonwhite card (NWC) and private (P) patients (Figure 6A). The patient who showed cardiac abnormalities was further subclassified to bring out the disease pattern and prevalence at the remote center (Figure 6B). Figure 6C gives an overview of the patients who were medically managed and those who needed further investigation/ interventions. Out of the 1207 (Figure 6D) abnormal studies, as shown in Figure 6C, 993 (82%) of them were medically managed without them having to travel to city, 79 (7%) of them needed further evaluation for confirming treatment, and 135 (11%) of them needed immediate interventions. The patients of the first category derived maximum benefits as they had necessary cardiac care without having to come to any tertiary care center. The patients and their attendees of the next 2 categories were benefited in that they were provided a complete picture of all the procedures and outcomes that they were likely to go through. The level of mental preparedness helps to buffer the patients both psychologically and financially for any eventuality, which would have been lacking if they would have needed to travel to a distant tertiary center. Table 4 lists the costs involved in getting the same tests done at any private center in the city as against the same done through this methodology. A conservative assumption was made for the costs involved in travel, food, and miscellaneous expenditure. Some cases (Figure 7A) reported from the district hospital Mahabubnagar.
that can be assessed. Images may be stored both locally and remotely on off-line media such as tape or optical media, or partially or exclusively on hard disks (‘spinning’) media. The latter is becoming more common. The hard drives may be configured and attached to the PACS server in various ways, either as direct-attached storage (DAS), network-attached storage (NAS), or via a storage area network (SAN). Today, newer techniques which employ cloud computing are being adopted to ensure that the healthcare provider does not have the issue of worrying about storage or bandwidth for transmission of high voluminous data. This quick retrieval of information will help in research, educational, and epidemiological work apart from ensuring that a good comprehensive electronic medical record (EMR) of the patient information is obtained. The availability of a good PACS system will eventually allow us to develop new structured reporting formats that will lead to a drastic reduction in the reporting time.
OUR EXPERIENCES Mooted by the inspiration of Dr. APJ Abdul Kalam, former President of India, to ensure accessibility of quality healthcare delivery systems to people living in remote centers (Figure 3), we developed a telemedicine system under a public private partnership model with the Andhra Pradesh Vaidya Vidhana Parishad (APVVP) (Government of AP) connecting the district hospital at Mahabubnagar to CARE Hospital at Hyderabad. Care was also the nodal agency for the pilot study initiated by the Government of India as a part of the 54-nation PAN African network. The pilot study was with Black Lion Hospital, Ethiopia for tele-consultations. Presently the link is used actively to provide continuous medical education (CME) for the medical fraternity across the connected nations of the network. Real time methodology was adopted for viewing echocardiographic images with a trained technician at Mahabubnagar providing the views for the specialist at CARE. Store and forward methodology was adopted for reporting of CT cases. The network operates on a 256 Kbps leased line of point to point connectivity. Figure 4 illustrates our setup at Mahabubnagar district hospital. We currently have a 2 Mbps broadband based internet connectivity on which most of our telemedicine links work. The link which was inaugurated on 25th October 2001 by Shri N Chandrababu Naidu, (Figure 5) Chief Minister of Andhra Pradesh has been operational till date and is one of the very few practicing centers of telecardiology. A total of 20,000 cases (includes CT, ECG, and ECHO) have been done from the district hospital of Mahabubnagar as of July 2010. The number of ECHO examination done as of July 2010 is 3188. Data between January 2002 and July 2007 was analyzed thoroughly. Of the 2068 patients7 studied, as shown in Figure 6A, 861 (41%) were classified as normal. The remaining 1207 (59%) were diagnosed as ‘abnormal’, and comprised of those with a past history of cardiac illness or abnormal findings in the present investigations. Of these, 292 patients (24%) were diagnosed as JICC Vol 2 Issue 1
INITIATIVES IN INDIA Validation of the Process As a measure of validation of the entire process of reporting echocardiographic cases through telemedicine, we selected about 50 patients and repeated the echocardiographic investigation at CARE Hospital. The investigation was performed by a cardiologist who was different from the one who diagnosed through telemedicine. The analysis revealed that there was no discrepancy in the findings between both methodologies, thereby suggesting that the transmission of these images did not deter the quality of the images. 9
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Global System for Mobile Communications (GSM) versus Landline-Based Electrocardiography Transmission In collaboration with Cardguard (Hong Kong), we integrated an ECG machine which enabled acquisition and GSM transmission of ECG based on acoustics. The device (Figure 7B) enabled acquisition of ECG and transmitted the same through a mobile phone to a hub station for diagnosis. A pilot study was conducted to validate the quality of transmission and the time taken for transmission of the ECG through landline and mobile phone (Figure 7B). Samples from 50 patients were taken and transmitted both through landline and mobile phone (GSM enabled). The ECGs transmitted by both modes of communication were graded and results are shown in Table 5. Our study suggested that 100% readability was achieved for all ECGs transmitted through landline as compared to 72% readability was transmitted through mobile. Some of the reasons for the lesser percentage of readability through mobile could be: (i) Motion artifacts. (ii) Distance between the GSM transmitter and mobile and the kind of angulation used. (iii) Additional noise interference (adverse signal to noise ratio) from the surroundings while transmitting.
Multiparameter Device for Primary Healthcare A portable ruggedized simple cost-effective device (Figure 8) integrating 5 parameters namely ECG, BP, temperature, stethoscope, and oxygen saturation is currently being used as part of rural telemedicine project initiated by the CARE-Byrraju
Figure 5 Chief minister of Andhra Pradesh N Chandrababu Naidu interacting with telemedicine’s first patient on 25th October 2001.
Figure 3 Dr. APJ Abdul Kalam’s vision.
ECHO images DICOM/video
LAN ECG signals RS 232 Remote center
Specialty center
Figure 4 Telemedicine setup at district hospital, Mahabubnagar. DICOM: digital imaging and communications in medicine; ECG: electrocardiography; Echo: echocardiography; LAN: local area network.
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A
2500
C 1200
ECHO 2068
1000
2000
Series 1 993
No. of cases
1696 800 1500 600 1000 400 500
372
200
135
79 0
B
900
Free + WC
NWC + P Category
0
Total
Medical management
861
Further evaluation
Intervention
800
Female
Male
700
Total
Number
600
500
450 411
400 292
300 245
207 200
161 84
100
173
151 84
139
67 15 26
41
59
138 99
80
85
74 1 3 4
8
71 67
16 24
0 Normal
CAD
CMP
PAH
CHD
HHD
Mass
PD
RHD
VHD
Modality
D
861
1027
Normal study Positive study
Figure 6 (A) Categorization of patients based on cost. (B) Disease classification. (C) Outcomes of the abnormal study. (D) A diagrammatic representation of the total number of cases that were reported to the telemedicine unit, and the number who were showing cardiac abnormalities as against the normal studies. CAD: coronary artery disease; CHD: congenital heart disease; CMP: cardiomyopathy; ECHO: echocardiography; HHD: hypertensive heart disease; NWC: nonwhite card; PAH: pulmonary arterial hypertension; PD: pericardial disease; RHD: rheumatic heart disease; VHD: valvular heart disease; WC: white card.
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same with other application software, thereby raising the issue of interoperability. Advances in the telecommunication industry have made it possible of the evaluation of prosthetic valve sounds and providing cardiac defibrillation transtelephonically.
Foundation. The device enables transmission of the data through broadband internet with a bandwidth as low as 64 Kpbs. This makes it a very useful device to be used in remote areas where communication and bandwidth are a challenge and handy for dealing with cardiopulmonary emergencies in remote and hilly areas. It has practical application in managing the patients in transit and intra ambulance prehospital care. We also had another study for transmission of heart lung sounds through a digital stethoscope (Littman), which allowed for real time transmission of sounds as well as through store and forward methodology. However, one of the limitations was the cost associated with it and also the flexibility of integrating the
Other Centers The other centers that CARE is connected to are listed in the Table 6. Some Other Initiatives The Ministry of Communications and Information Technology, Government of India, has classified ‘telemedicine’ as one of the
Table 4 Cost analysis (values considered as of 2008).
Category Free + WC NWC + P
No. of patients 1696 372
Total Saving in cost
TMC cost (Rs) Per patient Total 300 508,800 600 223,200
Account head Test Travel Food
Per patient 900 200 200
2068 732,000 268,840 − 732,000 = 19,56,400 (73%)
Cost outside TMC (Rs) No. of patients 2068 2068 2068
Total 18,61,200 413,600 413,600 26,88,400
Free: it denotes cases where the patients are given free consultation with no charge levied on them; NWC + P: the nonwhite card and private patients are of the higher economic echelons that are capable of paying for the diagnostics and consultation; TMC: telemedicine center; WC (white card): these patients have a ration card (below poverty line) issued to them by the Government.
Patient’s name: J Age/Sex: 26/F
Complaints Chest pain since 4 days. General examination Feeling uneasy BP: 130/90 Echo report Congenital heart disease Large PDA (5 mm) with left to right shunt. No PAH. Dilated LV and LA. Atrial septal aneurysm. No coarct, VSD, ASD
Figure 7A (Continued).
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Patient’s name: J Age/Sex: 26/F
Complaints Chest pain since 1 month. BP: 130/90 mmHg Echo report Organic TV disease with moderate TR. Severe mitral stenosis. Moderate MR. No LA clot, mild PAH.
Patient’s name: J Age/Sex: 26/F
Complaints Chest pain since 4 days. General examination Feeling uneasy BP: 130/90 mmHg Echo report Congenital heart disease Large PDA (5 mm) with left to right shunt. No PAH. Dilated LV and LA. Atrial septal aneurysm. No coarct, VSD, ASD
Figure 7A Echocardiography and electrocardiography transmitted from Mahabubnagar. ASD: atrial septal defect; LA: left atrium; LV: left ventricle; MR: mitral regurgitation; PAH: pulmonary arterial hypertension; PDA: patent ductus arteriosus; TR: tricuspid regurgitation; TV: tricuspid valve; VSD: ventral septal defect.
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Figure 7B Electrocardiography device and global system for mobile communications-based transmission.
Table 5 Landline versus mobile transmission. Mode of transmission Landline Mobile
Acceptability (%) 64 24
Diagnosability (%) 36 48
Table 6 Centers connected to CARE. Nondiagnosable (%) 0 28
Location Singareni Colleries, Kothagudem Singareni Colleries, Ramagundam Mecure Diagnostic Center, Nigeria CARE-Byrraju Foundation (30 villages in the West Godavari District) GB Pant Hospital, Agartala, Tripura 54-nation PAN African Network (Govt. of India)
Modalities—Telemedicine ECG, ECHO, X-ray ECG, ECHO, X-ray X-ray, CT, MRI ECG ECG, ECHO Tele-education (CME)
CME: continuous medical education; CT: computed tomography; ECG: electrocardiography; ECHO: echocardiography; MRI: magnetic resonance imaging.
thrust areas for development in the country. In sync with the policy, the Government initiated a project called ‘Development of Telemedicine Technology’. The three tertiary level hospitals of North India were linked up using telemedicine application developed by Center for Development of Advanced Computing.10 This included the following institutes: 1. All India Institute of Medical Sciences at New Delhi. 2. Post Graduate Institute of Medical Education and Research (Nehru Hospital) at Chandigarh.
Figure 8 Multiparameter device.
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other medical equipments such as the ECG, blood counters, pathological equipment, etc which need to generate outputs in standard formats to be easily integrated to any application software. In our study we did realize that the factor to be addressed through this mode of technology is the ‘patient satisfaction’ quotient as we have the most important ‘feel factor’ between the doctor and patient interaction missing. However, we did have good video-conferencing systems set in place to at least have good quality interactive session between the patient and the doctor. Manpower continues to be one more area of concern and setting up video-conferencing systems and providing continuous training sessions through this link addresses this problem to some extent. Finally, a good cost-effective system that includes good application software, hardware, and communication mode to allow for the transfer of basic medical information from one place to the other is the need of the hour, especially if we have to visualize telemedicine as good effective healthcare delivery system to remote areas.
3. Sanjay Gandhi Postgraduate Institute of Medical Sciences at Lucknow, Uttar Pradesh. Some initiatives taken by players in this field are listed below: Apollo
Pioneer in starting a pilot project at a secondary level hospital in a village called Aragonda 16 Km from Chitoor (population 5000, Aragonda project) in Andhra Pradesh. Starting from simple web cameras and ISDN telephone lines, today, the village hospital has a state-of-the-art video-conferencing system and a Very Small Aperture Terminal (VSAT) satellite installed by Indian Space Research Organization (ISRO). Apollo has setup over 45 telemedicine centers across different locations in the country and many more are in the pipeline.
A center has been setup in Brickfields to allow the poor Narayana Hrudayalaya who are suffering from heart ailments to seek free Heart Institute treatment at the Narayana Hrudayalaya Heart Institute in Bengaluru, Karnataka. A tele-cardiology unit had been setup to enable the patients to communicate ‘face-to-face’ with the specialist providing expert advice from the heart hospital in Bengaluru, India. ISRO North East Telemedicine Project
CONCLUSION The advances made in communication technology have made it possible to have effective healthcare delivery systems through telemedicine. Telemedicine has made it possible to have patients always networked irrespective of their location. This has in fact also led to remote monitoring and diagnosis for patients with various disease conditions, which include even patients with implantable devices. An invaluable advantage of telemedicine by having networked patients is the availability of timely diagnosis.10 It is well known that the distance decay effects, i.e., distance in terms of cost and distance acting as a deterrent to people consulting is one important factor that telemedicine overcomes. Telemedicine cannot bring about cure to all the problems existent in the rural areas, but sure will help in addressing the vast range of problems. Telemedicine also ensures an increase in the general awareness of good health across the region due to the availability of specialist opinions. Our initiatives have also brought into realization that the same network link serves as an excellent method for training of paramedics and nurses and in keeping medical professionals at remote centers updated with the latest advances in medical sciences through CME programs.
Online telemedicine research institute along with ISRO started an ambitious project in the North Eastern part of India on 15th September 2001 on permanent basis. The project implemented by Online Telemedicine Research Institute; Space Application Center; Sundari District Hospital, Udaipur, Tripura and Rabindranath Tagore IICS, Kolkata.
Teleradiology Teleradiology Solutions was founded in 2002 by 2 Yale trained physicians, Dr. Arjun Kalyanpur and Dr. Sunita Solutions, Maheshwari. It was initially setup to provide hospitals Bengaluru in the USA with night shift radiology solutions. However, it grew rapidly and now provides teleradiology to hospitals in Singapore and India with other countries on the anvil. TRACIS
Teleradiology and Cardiac Imaging Solutions (TRACIS) has just been established in Hyderabad to provide teleradiology and cardiology solutions with innovative and simple reporting mechanisms. A pilot study with the CT center in San Francisco for reporting cardiac CTs is underway under the leadership of Dr. Ravi Bathina at CARE Hospitals, Hyderabad.
OBSTACLES AND CHALLENGES
ACKNOWLEDGMENTS
One of the major challenges that we in India still face inspite of the advances in communication technology is the reliability and accessibility of communication links to remote areas. While broadband internet technology has made great impact in the ways of life today, we still have not reached that percentage of reliability. The other main concern that comes up is the integratability of medical devices (appropriate interfaces) with application software. While DICOM standards have addressed most of these issues with imaging modalities, there are still
The contribution of Dr. Nitin K Rao, Dr. V Karani, Dr. AV Anjaneyulu, Dr. C Sridevi, Dr. K Raghu, Dr. Gokul Reddy, Consultant Cardiologists, Mr M Bhavan Kumar, Mr S Radhakrishna, Mr Subhash who handled the field operations and Ms Sangma, who compiled and analyzed the Mahabubnagar data are acknowledged. Prof Arun K Tiwari, Director, CARE Foundation who was instrumental in initiating and providing technical guidance to the telemedicine project is very much appreciated and acknowledged. ♦
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6.
Chow C, Cardona M, Raju PK, et al. Cardiovascular disease and risk factors among 345 adults in rural India—the Andhra Pradesh Rural Health Initiative. Int J Cardiol 2007;116:180–5. 7. Tiwari KA, Prasad SG, Sangma M, et al. Tele-medicine: an assessment for delivery of quality healthcare. Health and Population—Perspectives and Issues National Institute of Health and Family Welfare 2008; 31:82–188. 8. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA 1995;273:483–8. 9. Choplin RH, Boehme JM II, Maynard CD. Picture archiving and communication systems: an overview. Radiographics 1992;12:127–9. 10. GATS Report of India: Telemedicine Initiatives in India 96–101. 11. Hayes LD, Saxon AL. The value of Networked Patient: improving patient survival, CME released: 06/08/2010.
REFERENCES 1. Akselsen S, Eidsvik AK, Folkow T, et al. Telemedicine and ISDN, IEEE Communication Magazine 1993;31:46–51. 2. Bhargava A. Telemedicine: an opportunity in healthcare Feb 2010. http://www.slideshare.net/bamit/telemedicine-an-opportunityin-healthcare-in-India. 3. Ferrer–Roca O, Sosa-Iudicissa M, eds. Main telemedicine applications. In: Handbook of Telemedicine IOS Press 1998;Chap 3:63–5. 4. Joshi R, Cardona M, Iyengar S, et al. Chronic diseases now a leading cause of death in rural India—mortality data from the Andhra Pradesh Rural Health Initiative. Int J Epidemiol 2006;35:1522–9. 5. Chow CK, Raju PK, Raju R, et al. The prevalence and management of diabetes in rural India. Diabetes Care 2006;29 Health Module: p. 1717.
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life-like images and live ones too. After NASA used it efficiently for their staff, telemedicine was still elusive. With the growing aging population and physical disabilities, the medical industry realized that the same concept can be used for the elderly and the disabled. The whole idea behind the concept is to deliver medical help to a person where it is not possible to reach them immediately. For an elderly, a space station or their home has an equal value because they cannot reach out for medical help even if they want to.
P Krishnam Raju, MD DM* SG Prasad, BE MS**
TELEMEDICINE—NEED IN INDIA
ABSTRACT Information and communication technology (ICT) has enabled telemedicine to become an effective model for healthcare delivery. Patients have been networked irrespective of their location for remote monitoring and timely diagnosis with this technology. This article elaborates on our telemedicine experiences, methodologies adopted and highlights the various design aspects to be considered for making telemedicine effective. An important aspect that emerged from our study was that this technology can be utilized as an excellent screening tool for patients at remote centers and undertake preventive measures for potential patients at risk of cardiovascular disease.
The idea of performing medical examinations and evaluations through the telecommunication network is not new. Shortly after the invention of the telephone, attempts were made to transmit heart and lung sounds to a trained expert who could assess the state of the organs. This started as early as in 1906.2 India is a nation of 1.3 billion people populating a subcontinent sparsely in pristine landscapes or in a startling density in some of the world’s largest cities. In today’s world, with several advancements made in the medical field, still the benefits are available to the privileged few, residing mainly in the urban areas. India with its vast population of which 70% are poor and live in difficult to reach rural and inhospitable terrain find itself inaccessible to quality healthcare services. It must be noted that the average per capita spent on healthcare is 5.2% GDP, one of the lowest in the world and various healthcare indicators are also lower than the global average.2 The Government of India has been investing in telemedicine in a bid to make healthcare more accessible to the country’s rural communities. But skeptics are wary about the limitations of the technology when it comes to diagnosis, care, and surgery. This chapter here deals with the current scenario of telemedicine and cardiology in India, with special emphasis on telecardiology, while highlighting our own experiences over the last 1 decade. It primarily focuses on the requirements in terms of technology, communication, infrastructure, and human resources to ensure a practical workable model catering to the demands of our country.
Keywords Bandwidth, cardiology, CARE, HIPAA, ICT, PACS, telemedicine
INTRODUCTION In the last 4 or 5 years, telemedicine has generated immense interest among users and medical professionals. Telemedicine is actually a branch of science that has been based upon the use of telecommunications. Today, telecommunication has advanced gradually to a level where audio, video, and text are all possible at the same time. Simultaneously with the growth of telecommunication, even the telemedicine industry has been growing. However, telemedicine is not as new an industry as people think, and in fact, it has existed over 30 years in the medicine industry.1 National Aeronautics and Space Administration (NASA) had a big role to play in the popularity of telemedicine and they started using it when humans were being sent to space. When scientists were sent to space on space ships, their vital statistics and other health conditions were monitored through telemedicine. This development came in as early as 1960. However, after that communication industry has developed by leaps and bounds and today, complicated satellites are used for transmitting
Telemedicine—Definition ‘Telemedicine has been defined as the use of telecommunications to provide medical information and services’. The actual practice of telemedicine can be defined as integration of medical, communication, and information technology to provide medical advice on the basis of comprehensive information transferred from remote centers to specialty centers. If we were to talk from a layman’s point of view, we will not be absolutely wrong if a patient calls up a doctor on account of a headache and the doctor prescribes a medicine and define that as ‘telemedicine’. However, the issue that comes up with this is the fact that the transaction between the doctor and patient is not documented and this piece of information cannot be retrieved for any further reference. It is therefore imperative that we ensure that telemedicine services are used as judiciously as withdrawal of money from an ATM where everything is accounted.
*Consultant Cardiologist, Chairman, **Chief of Telemedicine, CARE Foundation, CARE Hospital, Road No. 1, Banjara Hills, Hyderabad – 500034, India. Correspondence: Dr. P Krishnam Raju, CARE Foundation, CARE Hospital, Road No. 1, Banjara Hills, Hyderabad – 500034, India. E-mail: [email protected]
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Burden in India—Coronary Heart Disease Mortality Statistics Specific mortality data ideal for making comparisons with other countries are not available in India. This is due to inadequate and inappropriate death certification, and multiple concurrent causes of death. The annual surveys conducted by the Registrar General of India cover about 0.5% of deaths in rural India. The figures published by the World Health Organization (WHO), drawn mainly from this source and for what they are worth, show a much higher prevalence in India than in many other developing countries. Diseases of the circulatory system are still one of the top 10 causes of death in rural India4 with comparable proportions of ischemic heart disease (IHD) and cerebrovascular disease comprising majority of deaths in this category. In another study conducted as a part of the Andhra Pradesh Rural Initiative (APRHI) in 20 villages (size 4535) it was observed that 13.2% of them suffered from diabetes, of which 6.4% were diagnosed and 6.8% undiagnosed. Also 15.5% of them were in the prediabetic stage5 (impaired glucose tolerance). Another study for the assessment of CVD and risk factors among 345 adults in rural India (APRHI) attributed 25.2% to smoking and 27% to hypertension.6 Even though the number of open-heart surgeries performed (42 operations per million) is small as compared to 1700 per million in the USA, it provides a clue to the enormous demand in India. There are approximately only 500 fully operational cardiac centers in India with surgical facilities. Clinical impression alone suggests that there has been phenomenal increase in IHD throughout India. As in other developing countries, the reasons are obvious. Increase in life expectancy (from 41 in 1961 to 65 for male and 67 for female in 2010), smoking, western-style diet (with increase in saturated fat, salt, calories, and less intake of fiber), and decreased physical activity resulting in obesity are all responsible. Urbanization and industrialization are on the increase and responsible for many of these changes in lifestyle.
Table 1 Health statistics. Population deprived of healthcare services Specialist healthcare providers in urban areas Allopathic doctors available per 1000 of population Doctors available per 1000 of urban population Doctors available per 1000 of rural population Relative cost of setting a 100 bed primary care hospital to a tertiary care superspecialty hospital Spend on healthcare as a % of GDP Government spend on healthcare as a % of GDP
>700 million 70% 0.6 2.97 0.50 1/10 5.2 0.9
GDP: gross domestic product.
Unlike our professionals in the West, where telemedicine is more often used as a ‘second opinion tool’, the lack of medical expertize or specialists even 100 Km away from cities, suggests that we often need telemedicine services to ensure that patients living here get their first opinion. So the whole perspective of the process of telemedicine in India is distinctly different from the West. Telemedicine—Actual Need of this Service Indian healthcare is very city centric and most of the healthcare services are highly skewed in favor of urban population, which is 28% of the Indian population. Table 1 highlights some of the details2 to corroborate this fact. Healthcare today involves multiple work centers and interdisciplinary work co-operation. In addition to this the increasing mobility of people and the actual time span between health episodes for patients have made it increasingly difficult for facilitating timely diagnosis. Moreover the lack of adequate infrastructure at district/rural hospitals and the unwillingness of people to travel to cities either due to lack of time/monetary constraints have left us with no choice but to evolve systems in a manner that quality healthcare services can be delivered with the use of the information and communication technology (ICT) platform. Telemedicine finds its application in various disciplines—the most notable being in radiology, cardiology, pathology, dermatology, and opthalmology.3
Risk Factors—Old and New The traditional risk factors such as smoking, high blood pressure (BP), high serum cholesterol level and diabetes are applicable to the majority of cases in India. The emerging risk factors— abdominal obesity, high triglycerides, insulin resistance, the so-called metabolic syndrome, elevated homocysteine levels, fibrinogen factors, etc.—need not be invoked to explain the present high incidence of heart attacks as they are yet to be proven conclusively as being causative in this era of evidencebased medicine. Control of the traditional risk factors and use of proven preventive strategies should suffice in any preventive program. Keeping all of the above in mind it has become imperative that secondary and primary healthcare infrastructures now have to be empowered by making available the expertize from these tertiary level centers located in the urban areas. This is where ‘telemedicine’ plays a very significant role. The greatest impact of telemedicine is on the patient, the family, and the community. Using telemedicine technologies reduces travel time and related stresses to the patient. In many
Need for Telemedicine in Cardiology Among the many health predictions for the new millennium, the most alarming is that of cardiovascular disease (CVD)— heart disease and stroke—topping the list for death and disability. While there are undoubted regional differences between the developed countries and other economies, the predictions for India by 2015 show a steady increase since 1985. The projected rate per 100,000 for 1985 for all ‘circulatory diseases’ was 145 males, 126 females; for 2000, 253 males and 204 females and for 2015, 295 males and 239 females, which is higher than that for other causes such as cancer. In a mortality surveillance study that was conducted in 45 villages (population 180,162) during the period 2003–2004 showed that 32.6% of all deaths were due to diseases of the cardiovascular system, of which 34.3% were males and 30.2% females.4 JICC Vol 2 Issue 1
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instances, patient movement would require travel by additional family members, day care costs, and time away from the job. This disruption in the local community can be avoided when proper technologies are used to bring the consulting specialist to the patient. Our experience with the district hospital Mahbubnagar7 revealed a cost saving of 73% because of providing echocardiography (ECHO) consultation through telemedicine.
Table 2 Categories of medical information. Basic categories
Textual data Images Audio and video
Activity categories
Clinical consults Doctor–patient interaction Education and administration
Factors that Drive Telemedicine • Need to decrease costs of day care through increased efficiency and decreased provider time in travel. • Detect disease early. • Need to increase access to care for underserved populations, which cover the war theatre zone, people living in inaccessible terrain and also natural disaster struck areas. • Convenience to patients, and facilitate follow-up care. • Desire to address new markets or new patient populations. • Local capacity building of healthcare workers. • Obtain epidemiological database to understand disease pattern across country. Telemedicine as a Process Telemedicine essentially involves the integration of three technologies: • Medical equipment (medical technology). • Electronic patient records and clinical data (information technology). • Mode of communication (communication technology).
C-Band dish
Medical Technology This includes the medical equipment and the interfaces available in them to integrate them with computer systems. In earlier days, all medical manufacturers had their own proprietary formats, which meant that the images acquired in machines could be viewed only in the same systems. This raised issues of interoperability and consequently the American Board of Radiology and National Engineers Manufacturing Association (NEMA)8 suggested that all medical equipment follow a standardized format for imaging–Digital Imaging and Communication System (DICOM). This ensured that all medical equipment generate an output, which can be viewed in any of the medical systems, thereby solving the interoperability issue.
Figure 1 KU-Band dish.
analog signals, which may be transported on C-Band or KUBand. The transmission and receive frequencies available with the C-Band (Tx—6 GHz; Rx—4 GHz) are much less than the respective frequencies available with the KU-Band (Tx—14 GHz; Rx—11 GHz). Satellite transmission requires an up-link to the satellite and a down-link to the location. The KU-Band (Figure 1) satellite dish is relatively small and portable on a truck compared to the C-Band dish. However, the range and sturdiness achieved with static dishes compared to the mobile dish is much higher. The advantage with satellite transmissions is that they have no boundary restrictions. It allows transmission of large amounts of information. It is ideal for sending visual information to multiple locations. However, the disadvantage is the cost. It is
Information Technology: This includes the kind of computer systems that are required in terms of clients and servers. This varies from site-to-site based on the actual modalities integrated for telemedicine. The system architecture involves the operation and transfer of medical information in multiple categories that are defined in Table 2. Communication Technology The transmission mode may be transported via satellite or terrestrial media. Terrestrial modes include microwave, fiber-optic, and conditioned copper cables. Satellite transmission allows a full motion broadcast quality picture. Most satellites transmit JICC Vol 2 Issue 1
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approximately 8 times as expensive as terrestrial transmission. On the other hand, terrestrial transmission is less expensive to operate on an hourly basis but is limited to areas that are linked to the appropriate line. Video transmission normally requires a bandwidth (carrying capacity) of 90 million bits per second (Mbps). A telephone call requires 64,000 bits per second. The fastest speed available with current digital technology is 1.54 Mbps. This requires a bandwidth commonly referred to as T1. T1 consists of 24 voice channels, which may be combined with higher bandwidth as needed. The higher the bandwidth, the better the image quality, however, increased cost is the trade-off for better image quality. Fiber-optics is available from long distance and local telephone companies. Optical fibers consist of strands of hair-thin glass and uses light to transmit telecommunication signals. They may be leased as a dedicated line or on-demand basis. Optical-fiber has a wide bandwidth allowing for choices of transmission speed. Due to cost constraints, T1 line is not available in all areas. Today with the advent of broadband internet technology, accessibility at an affordable cost has become a reality and most applications are now based on web technology. One of the key parameters to be assessed as described above is the ‘bandwidth factor’, whenever we talk of communication. A simple equation which will help us in determining this is given below. Image resolution =
important to ensure that there is no compromise between video (of medical images) and audio (voice). Typical applications are echo, ultrasound, cath procedures. This would involve direct interaction between the expert–physician–patient at the time of the investigation. Consequently, a best practice is to have a prefixed scheduled time for this kind of methodology. Near Real Time This include application like electrocardiography (ECG) wherein there is an acquisition time involved for taking an ECG and then followed by transmission through the appropriate port. Store and Forward This typically is used for static images such as X-ray, computed tomography (CT) scan, magnetic resonance imaging (MRI). The advantage of this mode of communication is that one can archive all the images and then forward all the cases simultaneously, thereby reducing usage time of connectivity between locations.
APPLICATION SOFTWARE The software design should provide a unique patient identification numbers to archive records with necessary clinical information and retrieved at any point of time. The basic architecture (Figure 2) should comprise of: The application software should be designed keeping in mind perspectives of 5 users: • Patient—who would use the service • Primary health center (PHC)—which has trained medical personnel
Bandwidth × Cost Transmission time
Table 3 gives us an idea of bandwidth requirements for various applications.
METHODOLOGIES Real Time This typically includes transmission of dynamic images with minimum delay. The bandwidth for such applications is
User interface Image acquisition system
Table 3 Bandwith requirements. Modality Textual information Images transfer (like ECG, or jpg formats) Images (CT, MRI) DICOM format Echocardiography (live) Angiography Surgical Simple video-conferencing (for tele-consultation)
Backplane
Bandwidth (Kbps) 64 128 192 256 384 512 >1000 √ √ √
Processing
Communications
√√ √
√
Patient records
√√ √
Protocols
√√ √
Acquires images and data from the medical equipment Stores and retrieves patient data Secure, transfers data, allocates bandwidth Interacts with the system
√√
√√
Unites the serivce areas Performs specialized image manipulation
√: minimum requirement; √√: preferred requirement. CT: computed tomography; DICOM: digital imaging and communications in medicine; ECG: electrocardiography; MRI: magnetic resonance imaging.
Figure 2 Application software architecture.
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the privacy of patient health information. Further, lack of proper vigilance at remote settings attracts hostile intrusion from both hackers and virus. To fortify the telemedicine network against unauthorized access, some stringent security features in the network can be incorporated: • All the e-mail communications should be in encrypted form. The e-mail content is encrypted into strings of codes and transmitted over the network. At the receiving end, the coded message is assembled back into original form with help of a key. Even if someone manages to access it illegally during the course of transmission, the coded message will make no sense. • Facial recognition system helps the service providers to clearly identify the patients on the network, especially in the case of video-conferencing. • Digital identity card is provided to the remote patients after identity verification by authorities. The encryption features and digital signature of the patients in the card authenticates the users and allows them to access online health services. • The access to all the point-of-service computers should be user authenticated, to ensure that only authorized personnel access the system. • The computer network should be protected by firewall and should be constantly monitored to detect any intrusion. There should be an audit system, which maintains a record of time, frequency, and nature of the hostile attacks made on the network. The security features in the network enable the health service providers to provide quality healthcare services to remote patients in a safe and secure way. The patient health privacy is protected and this is in line with HIPAA compliance norms, thereby ensuring that telemedicine can safely deliver customized health solutions to remote communities.
• Expert center/specialist—involved in consultations • Medical administrator—who administers the network • Expert or doctor—who gives opinions and interacts with the patient. A good telemedicine system should be designed to achieve the following: Precise Definition It gives a graphical user interface, provides an immediate, selfexplanatory real time access to all the available data of a single individual patient as well as defined patient samples. It gives a precise description of the problem rather than part of the solution. Logical Processing This system creates an integrated patients record, own a central function in the hospital context, the integration of a knowledge base into this record, and to develop testing facilities for clinical data’s processing and for clinical support systems. It includes all patient related data, necessary administrative, and organizational data from all involved departments, and also some decision support from those departments. The Medical Record The patient record consists of modules of a database that are constructed according to logical integrated complexes: modules for demographic data, scheduling, subjective complaints and physical (SAP) findings exist: grouped data as the finding of a complex investigation or therapy exist as well as a problem list and a toll for the reimbursement. Downloading of parts of the patients record both textual and DICOM compatible images to intelligent terminals, where processing can be performed, and uploading of updated data are the main principles on the system.
Retrieval and Archival In medical imaging, electronic picture archiving and communication systems (PACS) have been developed in an attempt to provide economical storage, rapid retrieval of images, access to images acquired with multiple modalities, and simultaneous access at multiple sites.9 Digital medical images are typically stored locally on a PACS for retrieval. It is important that facilities have a means of recovering images in the event of an error or disaster. While each facility is different, the goal in image back-up is to make it automatic and as easy to administer as possible. The hope is that the copies won’t ever be needed but as with other disaster recovery and business continuity planning, they need to be available if needed. Ideally, copies of images should be streamed off-site as they are created. Depending on upload bandwidth and image volume, this may not be practical if the back-up system cannot be configured to tune bandwidth usage and frequency of back-ups. Other options include removable media (hard drives, DVDs or other media that can hold many patients’ images) that is physically transferred offsite. The content of these copies must be protected via encryption from exposure to unauthorized personnel or stiff penalties
Clinical Workstations A cornerstone of this system is a problem list with a distinction between active and inactive problems. The system uses relational database technology. The system is one of the models of medical records, which supports the medical user in the most advanced way with a maximum amount of structured information in relation to the actual processed data of the individual patients. Security Since information is exchanged over a great distance, through a series of local and wireless networks, the remote settings of the patients make the exchange of health information with health providers highly vulnerable to hostile intrusion. The Health Insurance Portability and Accountability Act (HIPAA) compliance norms makes it mandatory for all the covered entities like hospitals, clinics, clearing-houses, physicians, medical insurance companies, and other health service providers to employ secure computer network systems, which follow stringent security codes. The nomadic or remote settings of the patients make it a challenging task for the health providers to maintain JICC Vol 2 Issue 1
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having rheumatic heart disease (RHD), 139 patients (11%) as having congenital heart disease (CHD), 245 patients (21%) as having coronary artery disease (CAD), 138 patients (11%) as having nonrheumatic valvular heart disease (VHD), 173 patients (14%) as having hypertensive heart disease (HHD), 151 patients (13%) as having cardiomyopathy (CMP), 41 patients (3%) as having pulmonary arterial hypertension (PAH), 24 patients (1%) as having pericardial disease (PD), and 4 patients (0.3%) were diagnosed with cardiac masses. Percentage mentioned for all the abnormal cases refer to a cumulative count as a patient could have had more than 1 disease condition. Free cases and white card (WC) patient were poor and/or below poverty line patients who were charged nominal rates, as against nonwhite card (NWC) and private (P) patients (Figure 6A). The patient who showed cardiac abnormalities was further subclassified to bring out the disease pattern and prevalence at the remote center (Figure 6B). Figure 6C gives an overview of the patients who were medically managed and those who needed further investigation/ interventions. Out of the 1207 (Figure 6D) abnormal studies, as shown in Figure 6C, 993 (82%) of them were medically managed without them having to travel to city, 79 (7%) of them needed further evaluation for confirming treatment, and 135 (11%) of them needed immediate interventions. The patients of the first category derived maximum benefits as they had necessary cardiac care without having to come to any tertiary care center. The patients and their attendees of the next 2 categories were benefited in that they were provided a complete picture of all the procedures and outcomes that they were likely to go through. The level of mental preparedness helps to buffer the patients both psychologically and financially for any eventuality, which would have been lacking if they would have needed to travel to a distant tertiary center. Table 4 lists the costs involved in getting the same tests done at any private center in the city as against the same done through this methodology. A conservative assumption was made for the costs involved in travel, food, and miscellaneous expenditure. Some cases (Figure 7A) reported from the district hospital Mahabubnagar.
that can be assessed. Images may be stored both locally and remotely on off-line media such as tape or optical media, or partially or exclusively on hard disks (‘spinning’) media. The latter is becoming more common. The hard drives may be configured and attached to the PACS server in various ways, either as direct-attached storage (DAS), network-attached storage (NAS), or via a storage area network (SAN). Today, newer techniques which employ cloud computing are being adopted to ensure that the healthcare provider does not have the issue of worrying about storage or bandwidth for transmission of high voluminous data. This quick retrieval of information will help in research, educational, and epidemiological work apart from ensuring that a good comprehensive electronic medical record (EMR) of the patient information is obtained. The availability of a good PACS system will eventually allow us to develop new structured reporting formats that will lead to a drastic reduction in the reporting time.
OUR EXPERIENCES Mooted by the inspiration of Dr. APJ Abdul Kalam, former President of India, to ensure accessibility of quality healthcare delivery systems to people living in remote centers (Figure 3), we developed a telemedicine system under a public private partnership model with the Andhra Pradesh Vaidya Vidhana Parishad (APVVP) (Government of AP) connecting the district hospital at Mahabubnagar to CARE Hospital at Hyderabad. Care was also the nodal agency for the pilot study initiated by the Government of India as a part of the 54-nation PAN African network. The pilot study was with Black Lion Hospital, Ethiopia for tele-consultations. Presently the link is used actively to provide continuous medical education (CME) for the medical fraternity across the connected nations of the network. Real time methodology was adopted for viewing echocardiographic images with a trained technician at Mahabubnagar providing the views for the specialist at CARE. Store and forward methodology was adopted for reporting of CT cases. The network operates on a 256 Kbps leased line of point to point connectivity. Figure 4 illustrates our setup at Mahabubnagar district hospital. We currently have a 2 Mbps broadband based internet connectivity on which most of our telemedicine links work. The link which was inaugurated on 25th October 2001 by Shri N Chandrababu Naidu, (Figure 5) Chief Minister of Andhra Pradesh has been operational till date and is one of the very few practicing centers of telecardiology. A total of 20,000 cases (includes CT, ECG, and ECHO) have been done from the district hospital of Mahabubnagar as of July 2010. The number of ECHO examination done as of July 2010 is 3188. Data between January 2002 and July 2007 was analyzed thoroughly. Of the 2068 patients7 studied, as shown in Figure 6A, 861 (41%) were classified as normal. The remaining 1207 (59%) were diagnosed as ‘abnormal’, and comprised of those with a past history of cardiac illness or abnormal findings in the present investigations. Of these, 292 patients (24%) were diagnosed as JICC Vol 2 Issue 1
INITIATIVES IN INDIA Validation of the Process As a measure of validation of the entire process of reporting echocardiographic cases through telemedicine, we selected about 50 patients and repeated the echocardiographic investigation at CARE Hospital. The investigation was performed by a cardiologist who was different from the one who diagnosed through telemedicine. The analysis revealed that there was no discrepancy in the findings between both methodologies, thereby suggesting that the transmission of these images did not deter the quality of the images. 9
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Global System for Mobile Communications (GSM) versus Landline-Based Electrocardiography Transmission In collaboration with Cardguard (Hong Kong), we integrated an ECG machine which enabled acquisition and GSM transmission of ECG based on acoustics. The device (Figure 7B) enabled acquisition of ECG and transmitted the same through a mobile phone to a hub station for diagnosis. A pilot study was conducted to validate the quality of transmission and the time taken for transmission of the ECG through landline and mobile phone (Figure 7B). Samples from 50 patients were taken and transmitted both through landline and mobile phone (GSM enabled). The ECGs transmitted by both modes of communication were graded and results are shown in Table 5. Our study suggested that 100% readability was achieved for all ECGs transmitted through landline as compared to 72% readability was transmitted through mobile. Some of the reasons for the lesser percentage of readability through mobile could be: (i) Motion artifacts. (ii) Distance between the GSM transmitter and mobile and the kind of angulation used. (iii) Additional noise interference (adverse signal to noise ratio) from the surroundings while transmitting.
Multiparameter Device for Primary Healthcare A portable ruggedized simple cost-effective device (Figure 8) integrating 5 parameters namely ECG, BP, temperature, stethoscope, and oxygen saturation is currently being used as part of rural telemedicine project initiated by the CARE-Byrraju
Figure 5 Chief minister of Andhra Pradesh N Chandrababu Naidu interacting with telemedicine’s first patient on 25th October 2001.
Figure 3 Dr. APJ Abdul Kalam’s vision.
ECHO images DICOM/video
LAN ECG signals RS 232 Remote center
Specialty center
Figure 4 Telemedicine setup at district hospital, Mahabubnagar. DICOM: digital imaging and communications in medicine; ECG: electrocardiography; Echo: echocardiography; LAN: local area network.
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A
2500
C 1200
ECHO 2068
1000
2000
Series 1 993
No. of cases
1696 800 1500 600 1000 400 500
372
200
135
79 0
B
900
Free + WC
NWC + P Category
0
Total
Medical management
861
Further evaluation
Intervention
800
Female
Male
700
Total
Number
600
500
450 411
400 292
300 245
207 200
161 84
100
173
151 84
139
67 15 26
41
59
138 99
80
85
74 1 3 4
8
71 67
16 24
0 Normal
CAD
CMP
PAH
CHD
HHD
Mass
PD
RHD
VHD
Modality
D
861
1027
Normal study Positive study
Figure 6 (A) Categorization of patients based on cost. (B) Disease classification. (C) Outcomes of the abnormal study. (D) A diagrammatic representation of the total number of cases that were reported to the telemedicine unit, and the number who were showing cardiac abnormalities as against the normal studies. CAD: coronary artery disease; CHD: congenital heart disease; CMP: cardiomyopathy; ECHO: echocardiography; HHD: hypertensive heart disease; NWC: nonwhite card; PAH: pulmonary arterial hypertension; PD: pericardial disease; RHD: rheumatic heart disease; VHD: valvular heart disease; WC: white card.
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same with other application software, thereby raising the issue of interoperability. Advances in the telecommunication industry have made it possible of the evaluation of prosthetic valve sounds and providing cardiac defibrillation transtelephonically.
Foundation. The device enables transmission of the data through broadband internet with a bandwidth as low as 64 Kpbs. This makes it a very useful device to be used in remote areas where communication and bandwidth are a challenge and handy for dealing with cardiopulmonary emergencies in remote and hilly areas. It has practical application in managing the patients in transit and intra ambulance prehospital care. We also had another study for transmission of heart lung sounds through a digital stethoscope (Littman), which allowed for real time transmission of sounds as well as through store and forward methodology. However, one of the limitations was the cost associated with it and also the flexibility of integrating the
Other Centers The other centers that CARE is connected to are listed in the Table 6. Some Other Initiatives The Ministry of Communications and Information Technology, Government of India, has classified ‘telemedicine’ as one of the
Table 4 Cost analysis (values considered as of 2008).
Category Free + WC NWC + P
No. of patients 1696 372
Total Saving in cost
TMC cost (Rs) Per patient Total 300 508,800 600 223,200
Account head Test Travel Food
Per patient 900 200 200
2068 732,000 268,840 − 732,000 = 19,56,400 (73%)
Cost outside TMC (Rs) No. of patients 2068 2068 2068
Total 18,61,200 413,600 413,600 26,88,400
Free: it denotes cases where the patients are given free consultation with no charge levied on them; NWC + P: the nonwhite card and private patients are of the higher economic echelons that are capable of paying for the diagnostics and consultation; TMC: telemedicine center; WC (white card): these patients have a ration card (below poverty line) issued to them by the Government.
Patient’s name: J Age/Sex: 26/F
Complaints Chest pain since 4 days. General examination Feeling uneasy BP: 130/90 Echo report Congenital heart disease Large PDA (5 mm) with left to right shunt. No PAH. Dilated LV and LA. Atrial septal aneurysm. No coarct, VSD, ASD
Figure 7A (Continued).
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Patient’s name: J Age/Sex: 26/F
Complaints Chest pain since 1 month. BP: 130/90 mmHg Echo report Organic TV disease with moderate TR. Severe mitral stenosis. Moderate MR. No LA clot, mild PAH.
Patient’s name: J Age/Sex: 26/F
Complaints Chest pain since 4 days. General examination Feeling uneasy BP: 130/90 mmHg Echo report Congenital heart disease Large PDA (5 mm) with left to right shunt. No PAH. Dilated LV and LA. Atrial septal aneurysm. No coarct, VSD, ASD
Figure 7A Echocardiography and electrocardiography transmitted from Mahabubnagar. ASD: atrial septal defect; LA: left atrium; LV: left ventricle; MR: mitral regurgitation; PAH: pulmonary arterial hypertension; PDA: patent ductus arteriosus; TR: tricuspid regurgitation; TV: tricuspid valve; VSD: ventral septal defect.
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Figure 7B Electrocardiography device and global system for mobile communications-based transmission.
Table 5 Landline versus mobile transmission. Mode of transmission Landline Mobile
Acceptability (%) 64 24
Diagnosability (%) 36 48
Table 6 Centers connected to CARE. Nondiagnosable (%) 0 28
Location Singareni Colleries, Kothagudem Singareni Colleries, Ramagundam Mecure Diagnostic Center, Nigeria CARE-Byrraju Foundation (30 villages in the West Godavari District) GB Pant Hospital, Agartala, Tripura 54-nation PAN African Network (Govt. of India)
Modalities—Telemedicine ECG, ECHO, X-ray ECG, ECHO, X-ray X-ray, CT, MRI ECG ECG, ECHO Tele-education (CME)
CME: continuous medical education; CT: computed tomography; ECG: electrocardiography; ECHO: echocardiography; MRI: magnetic resonance imaging.
thrust areas for development in the country. In sync with the policy, the Government initiated a project called ‘Development of Telemedicine Technology’. The three tertiary level hospitals of North India were linked up using telemedicine application developed by Center for Development of Advanced Computing.10 This included the following institutes: 1. All India Institute of Medical Sciences at New Delhi. 2. Post Graduate Institute of Medical Education and Research (Nehru Hospital) at Chandigarh.
Figure 8 Multiparameter device.
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other medical equipments such as the ECG, blood counters, pathological equipment, etc which need to generate outputs in standard formats to be easily integrated to any application software. In our study we did realize that the factor to be addressed through this mode of technology is the ‘patient satisfaction’ quotient as we have the most important ‘feel factor’ between the doctor and patient interaction missing. However, we did have good video-conferencing systems set in place to at least have good quality interactive session between the patient and the doctor. Manpower continues to be one more area of concern and setting up video-conferencing systems and providing continuous training sessions through this link addresses this problem to some extent. Finally, a good cost-effective system that includes good application software, hardware, and communication mode to allow for the transfer of basic medical information from one place to the other is the need of the hour, especially if we have to visualize telemedicine as good effective healthcare delivery system to remote areas.
3. Sanjay Gandhi Postgraduate Institute of Medical Sciences at Lucknow, Uttar Pradesh. Some initiatives taken by players in this field are listed below: Apollo
Pioneer in starting a pilot project at a secondary level hospital in a village called Aragonda 16 Km from Chitoor (population 5000, Aragonda project) in Andhra Pradesh. Starting from simple web cameras and ISDN telephone lines, today, the village hospital has a state-of-the-art video-conferencing system and a Very Small Aperture Terminal (VSAT) satellite installed by Indian Space Research Organization (ISRO). Apollo has setup over 45 telemedicine centers across different locations in the country and many more are in the pipeline.
A center has been setup in Brickfields to allow the poor Narayana Hrudayalaya who are suffering from heart ailments to seek free Heart Institute treatment at the Narayana Hrudayalaya Heart Institute in Bengaluru, Karnataka. A tele-cardiology unit had been setup to enable the patients to communicate ‘face-to-face’ with the specialist providing expert advice from the heart hospital in Bengaluru, India. ISRO North East Telemedicine Project
CONCLUSION The advances made in communication technology have made it possible to have effective healthcare delivery systems through telemedicine. Telemedicine has made it possible to have patients always networked irrespective of their location. This has in fact also led to remote monitoring and diagnosis for patients with various disease conditions, which include even patients with implantable devices. An invaluable advantage of telemedicine by having networked patients is the availability of timely diagnosis.10 It is well known that the distance decay effects, i.e., distance in terms of cost and distance acting as a deterrent to people consulting is one important factor that telemedicine overcomes. Telemedicine cannot bring about cure to all the problems existent in the rural areas, but sure will help in addressing the vast range of problems. Telemedicine also ensures an increase in the general awareness of good health across the region due to the availability of specialist opinions. Our initiatives have also brought into realization that the same network link serves as an excellent method for training of paramedics and nurses and in keeping medical professionals at remote centers updated with the latest advances in medical sciences through CME programs.
Online telemedicine research institute along with ISRO started an ambitious project in the North Eastern part of India on 15th September 2001 on permanent basis. The project implemented by Online Telemedicine Research Institute; Space Application Center; Sundari District Hospital, Udaipur, Tripura and Rabindranath Tagore IICS, Kolkata.
Teleradiology Teleradiology Solutions was founded in 2002 by 2 Yale trained physicians, Dr. Arjun Kalyanpur and Dr. Sunita Solutions, Maheshwari. It was initially setup to provide hospitals Bengaluru in the USA with night shift radiology solutions. However, it grew rapidly and now provides teleradiology to hospitals in Singapore and India with other countries on the anvil. TRACIS
Teleradiology and Cardiac Imaging Solutions (TRACIS) has just been established in Hyderabad to provide teleradiology and cardiology solutions with innovative and simple reporting mechanisms. A pilot study with the CT center in San Francisco for reporting cardiac CTs is underway under the leadership of Dr. Ravi Bathina at CARE Hospitals, Hyderabad.
OBSTACLES AND CHALLENGES
ACKNOWLEDGMENTS
One of the major challenges that we in India still face inspite of the advances in communication technology is the reliability and accessibility of communication links to remote areas. While broadband internet technology has made great impact in the ways of life today, we still have not reached that percentage of reliability. The other main concern that comes up is the integratability of medical devices (appropriate interfaces) with application software. While DICOM standards have addressed most of these issues with imaging modalities, there are still
The contribution of Dr. Nitin K Rao, Dr. V Karani, Dr. AV Anjaneyulu, Dr. C Sridevi, Dr. K Raghu, Dr. Gokul Reddy, Consultant Cardiologists, Mr M Bhavan Kumar, Mr S Radhakrishna, Mr Subhash who handled the field operations and Ms Sangma, who compiled and analyzed the Mahabubnagar data are acknowledged. Prof Arun K Tiwari, Director, CARE Foundation who was instrumental in initiating and providing technical guidance to the telemedicine project is very much appreciated and acknowledged. ♦
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6.
Chow C, Cardona M, Raju PK, et al. Cardiovascular disease and risk factors among 345 adults in rural India—the Andhra Pradesh Rural Health Initiative. Int J Cardiol 2007;116:180–5. 7. Tiwari KA, Prasad SG, Sangma M, et al. Tele-medicine: an assessment for delivery of quality healthcare. Health and Population—Perspectives and Issues National Institute of Health and Family Welfare 2008; 31:82–188. 8. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA 1995;273:483–8. 9. Choplin RH, Boehme JM II, Maynard CD. Picture archiving and communication systems: an overview. Radiographics 1992;12:127–9. 10. GATS Report of India: Telemedicine Initiatives in India 96–101. 11. Hayes LD, Saxon AL. The value of Networked Patient: improving patient survival, CME released: 06/08/2010.
REFERENCES 1. Akselsen S, Eidsvik AK, Folkow T, et al. Telemedicine and ISDN, IEEE Communication Magazine 1993;31:46–51. 2. Bhargava A. Telemedicine: an opportunity in healthcare Feb 2010. http://www.slideshare.net/bamit/telemedicine-an-opportunityin-healthcare-in-India. 3. Ferrer–Roca O, Sosa-Iudicissa M, eds. Main telemedicine applications. In: Handbook of Telemedicine IOS Press 1998;Chap 3:63–5. 4. Joshi R, Cardona M, Iyengar S, et al. Chronic diseases now a leading cause of death in rural India—mortality data from the Andhra Pradesh Rural Health Initiative. Int J Epidemiol 2006;35:1522–9. 5. Chow CK, Raju PK, Raju R, et al. The prevalence and management of diabetes in rural India. Diabetes Care 2006;29 Health Module: p. 1717.
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