Introduction to Telemedicine by Levone

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									   Introduction to
   Arun Raj Kunwar, M.D.
     Assistant Professor
SUNY Upstate Medical University
       Syracuse, NY

• No financial affiliations or interest in any
  thing that will be discussed

• No commercial interest
              What is TM
• Use of telecommunications to provide
  medical information and services
• Health delivery/consultations via use of
  -Telephone between two providers
  -Video conference
  -Robotic technology
        Types of Technology

• Store and forward
  -Digital images are stored and forwarded
  -Digital X-rays, digital photos, EKG faxes
  -Mainly used for non-emergent cases but
  done for some emergent cases too
  -Can be forwarded to anywhere in the
         Store and Forward
• Teleradiology, the sending of x-rays, CT
  scans, or MRIs (store-and-forward
  images) is the most common application of
  telemedicine in use today
 -Most radiologists are staying home during
  on call
• Telepathology/ Teledermatology
   Two-way Interactive Television
• Face-to-face consultation
• Provides a real time consultations via
• Usually patient with their primary provider
  gets direct consultations to expert in
  distant site
• Can directly involve patient
• Widely used for urban-rural location where
  access to care is difficult
 -the patient does not have to travel to an
  urban area to see a specialist
 -availability of specialist services not
  available before
      IATV: Videoconferencing
• New ones are more simpler, cheaper and
  easy to use
• New programs now use desktop
  videoconferencing systems
• Attachment of peripherals to make it more
  interactive such as attachment of
  stethoscope and otoscope, blood sugar
           Often Combination
•   Interactive
•   Store and forward
•   Audio-video still images
•   Web to transfer data/other web application
•   Web based/accessed health records
•   Electronic prescriptions
•   Wireless technology in emergency/
             Application: TM
•   Health care delivery
•   Health profession education
•   Health administration
•   Public health
•   Business
•   Libraries
•   School education
            Benefit of TM
• Breaks down barrier to distance/access

• Improves quality of care
  -By direct patient consultations/
  consultations to primary care
  -By providing easy access to education

• May lead to decrease health care cost
• Urban to rural for specialty/unavailable
• Mental health care to Jail population
• Hospice care
• Consults to school nurse
• Home telehealth and monitoring of chronic
  disease- Chronic heart disease
• Distant health teaching/ monitoring (video
  recording of exams)
• Telesurgery applications for battlefield via
  use of robot
• Teleradiology
• Telepathology
• Most of the medical specialty are using
  some form of telemedicine
           TM: Experience
• SUNY Upstate Child Psychiatric
  Consultations To Binghamton General
 -Child Psychiatry is a sever shortage
 -BGH has been unable to recruit a child
  psychiatrist for some time
             TM: Experience
• BMG runs a Child Psychiatry inpatient unit with a
  help of adult psychiatrists

• Child Psychiatrist located at SUNY Upstate at
  Syracuse consults via videoconferencing

• Typically includes, review of the case, talking
  with patients, families and treatment
     Barrier to Telemedicine
• Equipment and infrastructure:
 -Most telephone do not provide enough
 -Increasing web based application making
  it simpler
 -high bandwidth telecommunications
  access required for more sophisticated
  uses (Rural connectivity priority)
      Barrier to Telemedicine
• Licensing issues: Many states will not
  allow out-of-state physicians to practice

• Reimbursement: Many private insurers will
  not pay for it. In some states new laws that
  reimburses in same rate as face to face
      Barrier to Telemedicine
• Fear of malpractice suits physicians
• Acceptance of the technology and lack of
  hands-on interaction with patients
  (most patient satisfaction studies to date
  find patients on the whole satisfied with
  long distance care)
• Privacy issues
• Worry about depersonalizing health care
        Heath Care in Nepal
• Percentage of national budget in
  health:                       6.2
• Percentage of the current five-year plan
  allocation in health:   6.0
• GDP about 5%
 (Nepal Millennium Development Goals:
  Progress Report 2005)
• 24.1 percent of the population earn less
  than an dollar per day

• 31 percent of the population is living below
  poverty line (Nepal Millennium
  Development Goals: Progress Report
    Nepal: Basic Health Indicators

• Hospital beds per 10,000 population 4.26
• Number Physicians per 10,000: 2
• Nurses per 10,000 population: 2
• Urban population (%)14. 2001
 (Nepal Millennium Development Goals: Progress Report
       Population Distribution

• Due to the thinly scattered population
  profile in the hilly and mountainous
  regions, the accessibility to health facilities
  is still a problem Nepal
        Telemedicine: Nepal
• Nepal has large rural population with
  limited access to medical care

• Most of the health care experts and
  physicians are located in urban areas-
  mainly Kathmandu
       Telemedicine in Nepal
• Regional hospitals are presently
  connected via internet for health
  information access

• Limited use of technology for education
          Ministry of Health
• Telemedicine Project in Developmental

• ?Connect all health post center
      E-Network Research and
• Mahabir Pun

• have started the telemedicine program in
  three villages as a pilot project. Nangi,
  Ramche and Tikot, all of Myagdi District
  Myagdi District.
(Note: ngi – Nangi, rmc – Ramche, tkt – Tikot are the
villages where telemedicine program has been set up)
               TM: Nepal
• Om Hospital & Research Centre (P.) Ltd
  and Apollo hospital in New Delhi

• Dr. Mohan Raj Pradhan
  HealthNet Nepal
  -Store and forward method: feasibility
     Center for Nyaya Health Achham

• Nyaya Health is a 501(c)(3) nonprofit
  organization working to improve the health
  of poor communities in Nepal through the
  provision of medical and public health

   Center for Nyaya Health Achham

• Nyaya Health activities in Achham is a
  four-bed, five-room clinic focusing on
  primary care, maternal and child health,
  HIV, and tuberculosis

• Plans to develop Telemedicine to provide
  medical services at two sites in Achham
   Center for Nyaya Health Achham:
               TM Plan
• Email-based communication with specialists
  regarding complex patients as issues arise

• Voice-based communication with specialists on
  complex patients, potentially even in emergency

• Communication from clinicians at the center
  clinic with Community Health Workers in the
  villages, for assistance with triage and treatment
   Center for Nyaya Health Achham:
               TM Plan
• Cytopathological assessment of Pap smears for
  cervical cancer, via transmission of images
  through digital microscopy;
• Interpretation of complex ultrasound or X-ray
  images for direct patient care, training, and
  quality assurance;
• Reading of complex microscopy slides for
  patient care, training, and quality assurance;
   Center for Nyaya Health Achham:
             Along with TM

• Microfinancing

• Selling of goods/promotion of business
  thought internet
  Shahid Gangala National Heart
• Dr. Jyoti Bhattarai Kunwar recently got
  funded by International Diabetes

• To compare the effectiveness of diabetes
  care via TM in rural health post Vs
  treatment as usual
            Nepal TM: Goals
• Connecting all rural health posts to Internet
• Providing direct consultations for patient care
• Some specialty are easily adopted
  -Diabetes management
  -Preventive health education
          Nepal TM: Goals
• Partnering with leading international
  groups for expert and second opinion
  -Johns Hopkins Medicine International
  runs global "Medical Second Opinion"

• Also for education
Nepal: Health Profession Education

• Most of the lectures are videotaped and
  can be accessed from distant site
• Live lecture feeds
• Case discussions

• Can lead to saving in cost of travel for
  health workers
            Nepal TM: Barrier
• Lack of any law/regulation

• Rural and even urban connectivity/
  bandwidth limitations

• Funding
    Other uses of TM to enhance
        health care in Nepal

• Electronic medical records

• Google health service
       TM Nepal: Application
• Electronic prescription

• Known to reduce medication error/ saving
  significant cost/suffering
Nepal TM: Business Application
•   Out sourcing
•   Medical transcription
•   Software development/Medical records
•   Medical consultations-
•   Patient education

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