Docstoc

Breezecom Website

Document Sample
Breezecom Website Powered By Docstoc
					Title of the article

Revolutionising the primary health care in India through Telemedicine based on WIRELESS
WIDE AREA NETWORKING of hospitals and primary health care centers

Abstract

India’s primary health care (PHC) network is four decades old. It is plagued by many
problems like absenteeism of doctors at the PHC, lack of proper facilities and most
significantly lack proper referral services to hospitals and specialist centers. Due to these
reasons the utilisation and confidence in the PHC system is very low. Governments tried
various measure to improve the system and they proved to be marginal.

While telemedicine in developed countries is proving to be extremely helpful for referral and
other consultancies, most of the telemedicine projects in India are demonstrative, cost huge
monies for setting-up and maintain and not replicable over the thousands of PHCs in the
country. Emerging broadband wireless technologies offer a revolutionary solution to the issue
of Primary health through telemedicine in India. They cost very little to invest and it is possible
to connect an entire district (bigger than many counties in size and population) in India
consisting of 50 PHC and 10 hospitals with $100,000. They allow interactive video for
examination, consultation, training and other services. The system addresses the
absenteeism of doctors and can be run by a Nurse at the Primary health center and costs
little to maintain.

Key words

Tele medicine, Primary health care, India health care, broadband wireless technology,

Author and address

Ranganayakulu Bodavala, President
THRIVE
Volunteers for Rural Health, Education & Information Technology
Chintapally
Nalgonda district Andhra Pradesh, India
Email: ranga@thrive.in

Biographical notes

The author with a management, computer science and industrial background worked 10
years in public health system as a consultant and trainer to various state governments in
India. He worked in UN system in Asia and Africa. He has set up and heads an organisation
with the primary aim of bringing in industry technologies, processes and tools to the public
health management/rural development to improve the efficiency of the system and thereby
the improve the access and quality of care to the needy.
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




Introduction - Indian’s sagging primary health care network.

India started building its primary health care infrastructure way back in 1952
as part of the Community
                                                     Table 1 Quick reckoner of the Indian demographic
Development program, much
                                                     and health scenario (2001 census)1
before it formally accepted the
                                                     Total population                                      1,027,015,247
Alma Ata declaration of health
for all through the primary care                     Rural population                                      741,660,293
approach. The main stress of
the national health policy as                        No of inhabited villages                              0.58 million
adopted by the Indian
                                                     Birth rate urban (SRS)                                21.4
parliament in 1983 is the
                                                     Birth rate rural (SRS)                                29.3
provision of preventive,
                                                     Death rate urban (SRS)                                6.5
promotive and rehabilitative
                                                     Death rate rural (SRS)                                9.7
health services to the people,
                                                     IMR urban (SRS)                                       46
thus representing a shift from
                                                     IMR rural (SRS)                                       78
medical care to health care and
from urban to rural population.
Since 74% of the Indian population lives in the villages, the delivery of health
services to the rural masses holds the key and forms an integral part of their
socio-economic development. In essence, the prime objective is the provision
of universally acceptable and affordable health care to the communities.
Table 1 shows the brief facts about the India’s population.


Though government of India and the state government over 40 years invested
large sums of money in developing the primary health care infrastructure, its
operation and sustainability need much to be deserved. Main reason for the
non-performance or minimal performance of the PHC system is the doctors
and specialists non-presence in the PHCs. Other reasons could be the lack of
good equipment (though this problem is continuously addressed) medicines
etc.




                                                                                                                        1
   Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
   and primary health care centers




                                                                                               2
Table 2. NUMBER AND PROFILES OF RURAL HEALTH INSTITUTIONS

Facility                            Sub-center                        Primary Health Center                   Community Health Center

No. of Facilities (1997)            136339                            22010                                   2622
Building                            One room plus                     With small operation                    30-50-100 bedded hospital
                                                                      theatre and male and                    and major operation
                                                                      female wards, usually 6                 theatres etc.,
                                                                      beds.
Not having own buildings            72142                             8323                                    224
Equipment                           Mostly kits for delivery          Only minimal lab and OT                 Generally X- ray and other
                                    etc.,                             equipment                               items
Doctors/specialist                  None                              One or two. 30% formally                By norm 4 specialists but
                                                                      do not have the posts filled            usually one or two doctors
                                                                      up and 70% generally do                 function any time.
                                                                      not turn up every day
Para medical                        One ANM generally                 As per the norms—14                     As per the norms – 21
                                    reports in the PHC                personnel. The real pillar of           Personnel.
                                                                      the PHC system.
Vehicle                             None                              Around 20-30% have some                 70-80% have Jeep cum
                                                                      jeep cum pick-up vans.                  pick-up vans.
Location                            Big village                       Major village called                    Town of 20,000 and above
                                                                      Panchayats or mandal                    population.
                                                                      head quarters.
Others                              Last link in the Primary          On an average, 5 to 7 sub-              First referral hospital,
                                    Health chain                      centers are attached.                   usually have 3- 6 PHCs are
                                                                                                              attached.
Visual SAMPLES




   PRIMARY HEALTH CARE SYSTEM – PERFORMANCE AT THE LOWEST

         1. The scheme of Primary health center based health started in early 60s.
            Every year some numbers of PHCs have been added based on
            population norm.

         2. Usually the process of creating PHC is by upgrading the existing sub-
            center and calling it PHC. It is long time before the upgraded PHC gets
            the regular needed facilities of PHC.

         3. More than 50% of them are single doctor PHCs

         4. At any time 20% of the PHCs do not have any doctor posted.




                                                                                                                           2
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



     5. Nearly 80% of the doctors do not stay in the PHC village. The rest
        maintain nominal presence in the village and mostly operate from the
        basses in the near by cities.

     6. Since the doctors do not stay in the PHC village, most of the staff
        prefers not to stay in the PHC village. This is still worst with the sub-
        centers. ANMs usually do not stay there.

     7. The staff and doctor guard each other and generally through replies
        like - the doctor/staff are attending to a camp/tour.

     8. Only 30% of the doctors visit the PHCs in the Outpatient time and
        leave. The rest prefer to visit once or twice in a week.

     9. The emphasis of government in primary health is more on developing
        physical assets like buildings and equipment

     10. PHCs are (?) delivering only family planning services. Other services
         (as per the norms) are usually not attended to. To this extent the norms
         of services are seriously diluted.

     11. Out patient statistics (even the government level) show severe under
         utilization of PHC system.

     12. The facilities are developed and operated in such an incoherent way
         that severe water/electricity problem deters patients from staying in the
         PHC and makes the service delivery very difficult.

     13. The logic of developing them mostly outside the PHC village also
         creates a sense of distance to the patients who have to walk down to
         the PHC as most of the PHC villages do not have any internal
         transport.

     14. Disease surveillance is very weak and mostly ineffective. The critical
         aspect of Public health function is thus diluted. Every year government
         spends more money after the outbreak of either malaria or brain fever
         etc., Still it would not like to fix the system failure. Every thing has to be
         attended on a contingency basis at a huge public cost.

     15. Even after the development of 5 decades, government cannot boost of
         even at a single instance of death averted/ emergency by the
         ambulance facility which is available and common in countries like
         even Pakistan.

     16. Government unfortunately believes that buildings and equipment etc.,
         will deliver the services. The crucial aspect of human resource
         development is not attended. The key functionaries like district medical
         and health officers are not even trained once on management,
         leadership etc. It is the worst with the PHC medical officers. They are
         supposed to manage 20 other staff without any of those skills inducted.


                                                                                                                        3
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



          There are some budgets earmarked in the World Bank funded projects,
          but they are mostly unutilized and treated as savings.

GOVERNMENT RESPONSE TO DOCTORS ABSENTEEISM

     1. All levels of the government are aware about the doctor’s absenteeism.

     2. At the political level there is no seriousness to attend to this issue.
        Usually doctors enter into the government system with good political
        contacts/kinship. The respective MLA patronizes his associate doctor/s
        and work for their convenient postings/transfer.

     3. Administrative level is aware of the problem. Doctor administrators
        simply do not bother about the problem. IAS administrators try to solve
        the problem by planning to / running the PHCs with out the doctors.


These factors have eroded the confidence of the public in the PHC system
and the utilisation of these hospitals is far less than their capacity. This
accentuated the absenteeism of the doctors and in turn negligence by the
government. Various donor agencies like (USAID, DFID, DANIDA, JICA,
CIDA) and major NGOs like CARE have tried to address this issue in a
traditional way. They tried to build PHC infrastructure, augment medical
supplies and provided training to the PARA- MEDICAL personal. The results
are good but they are only marginal.

At this juncture we need some break through solution, some thing that
stirs the system to activity and rejuvenation. Emerging computing and
wireless technologies promise a revolution. They cost much less than
the bricks and mortal and they provide if not real but virtual
transportation of the patient and the needy to the places which
otherwise would cost thousands to go and have consultation.

Development Of Secondary Hospitals (Referral Hospitals Located In
Cities And District Head Quarters)

Most the referral hospitals are sufficiently staffed in an average state in India.
States like Andhra Pradesh, Maharashtra, Utter Pradesh, Karnataka, West
Bengal, Orissa, and Punjab have borrowed huge monies from the World Bank
and have developed/developing the secondary hospital infrastructure to the
satisfactory level3. The proposed wireless networking can link these hospitals
to the Primary health centers and also link the small-bedded (30, 50, 100)
hospitals to the district hospital.




                                                                                                                        4
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



In the light of the above observations, telemedicine which is fast emerging as
the viable model is examined in this article for supplementing/substituting and
enhancing the primary health care services in India. After examining the
existing projects and the models, a new model based on BROADBAND
WIRELESS NETWORK utilising the SPED SPECTRUM TECHNOLOGIES
is proposed between the district general hospitals to the other cities and to the
rural primary health centers.

The following section deals with the telemedicine, practices, technologies
abroad, issues in India and the viability of the present model.

TELEMEDICINE DEFINED

Telemedicine is a method, by which patients can be examined, investigated,
monitored and treated, with the patients and doctor located in different places.
Time magazine coined the phrase as ‘healing by wire’

The Institute of Medicine defines telemedicine as "...the use of electronic
information and communications technologies to provide and support health
care when distance separates the participants..."

Image acquisition, image storage, image display and processing, and image
transport represent the basis of telemedicine.

The most common applications today are in transmission of high-resolution X-
rays, cardiology, orthopaedics, dermatology and psychiatry. In developed
countries often, interactive video and audio are used for patient consultations
and guidance on procedures; sometimes-video briefings and records of
specific operations are kept on a network in digital form. Groups of physicians,
teachers and researchers often "meet" across large distances. Telemedicine
also embraces the management of electronic patient records, access to
libraries and databases on the Web and on private networks, and extensive
use of e-mail by many in the medical profession.

Telemedicine arose originally to serve rural populations, or any people who
are geographically dispersed -- where time and the cost of travel make access
to the best medical care difficult. Now, it is increasingly being used in
mainstream medicine, which is mostly located in urban metropolitan areas to
allow doctors the world over to share expensive resources and valuable
experience.

Telemedicine is increasingly global in its reach; in 2000 there were 763 active
programs around the world, including Israel, Chile, India, Taiwan, Japan and
the USA.

The availability of telemedicine is dependent to a large degree on
telecommunications, and on high bandwidth; the field is concerned with
advanced telecomm equipment and standards, methods of increasing
effective bandwidth and network performance, costs of installation and



                                                                                                                        5
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



operation, security, confidentiality and reliability, and with government
legislation aimed at furthering progress in these areas.

Telemedicine in the developed world is really "virtual transportation." In critical
situations, the ability to keep a patient where he is and not have to stage an
emergency evacuation, with all its costs and dangers, can be vital to the
patient's survival and quality of life. But in the developing world, telemedicine
delivers access to a high level of care where it is simply not available, at any
cost.

Thanks to the explosion in communications technology truly making the world
a global village, it has now become possible to diagnose a medical problem,
supervise a surgical procedure or give a doctor or a paramedical health
worker in a rural area valuable health information from hundreds, if not
thousands, of miles away.

It is worth examining the possibilities modern tele-revolution can hold out for a
country such as India, where the cream of medical specialities is concentrated
in urban centres, with some centres being more 'doctor-friendly' than others
While corporate hospitals in India may be lining up for services which will give
them the opportunity to have cross-consultations with the creme de la creme
of the medical community all around the world-for which probably,
administrators, especially those serving in the public health centre, definitely
need to sit up and take notice of this new area of medicine.

With almost every electrified village in the country having a television set
today, slowly, global village called the world. It is only a matter of time before
semi-urban and rural areas get connected to the rest of the world by a
computer first, e-mail next and the Internet eventually.

Scope of Telemedicine

The term telemedicine includes, in its scope, consultation by telephone, video
or e-mail and remote supervision of maladies and their treatment, especially
in the under-served areas. One of its benefits is the instant access it gives to
a doctor in a remote area expert advise to accurately diagnose a patient's
illness and provide specific treatment for it. Table 3 provides a brief
description of the various telemedicine projects in the developed countries
and Table 4 summarises the main telemedicine projects in India.




                                                                                                                        6
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




Table 3. brief description of various telemedicine projects in developed countries.

CAROLIN -                   Via Fucini, 2,            CAROLIN is a multimedia application for cardiology
Cooperative                 Milano, Italy             teleconsulting, developed in the framework of inter-
Application for             20133                     regional cooperation and sponsored by the European
Remote on-line                                        Union within the TeleRegions SUN Project. The
Interactive                 http://www.cef            primary aim is to facilitate and streamline remote
Diagnosis                   riel.it/item              exchange of clinical information while reproducing the
                                                      characteristics of a real consultation as closely as
                                                      possible. During the teleconsultation, the specialists
                                                      all have access to the same multimedial material,
                                                      they share the same images and annotations and
                                                      they may voice their comments through an integrated
                                                      video-conference system. The teleconsultation
                                                      achieved by CAROLIN is truly cooperative and
                                                      interactive since the system supplies the right
                                                      instruments for it: a Virtual Movieola (replay and slow-
                                                      motion device) to navigate through the sequences of
                                                      digital images, a shared whiteboard to manipulate
                                                      and annotate single images with text and graphic
                                                      comments; and an ISDN connection to hold an
                                                      audio/video conference between physicians. The
                                                      system was designed and developed to be
                                                      independent of any specific technology. It is therefore
                                                      easy to use, maintain and update
Telemedicina                CETT Ruta C-              The Telemedicine Program developed by the
CONAE                       45 Km 8,                  Comission Nacional de Actividades Espaciales of
                            Cordoba,                  Argentina (CONAE - Argentine Space Agency)
                            Falda de                  includes an international component, the
                            Caqete,                   ARGONAUTA program (Austral On-line Network for
                            Argentina                 Medical Auditing and Tele-assistance). One of the
                            5187                      major objectives of the project is the implementation
                                                      of facilities to improve the quality of , and access to,
                            http://www.tm.            health care, especially in rural areas. This Tele-
                            conae.gov.ar/             medical network consists of a central communication
                                                      node, three reference hospitals (principal nodes) and
                                                      telemedical stations in peripheral points (10 rural
                                                      hospitals at this time), such as regional hospitals,
                                                      Antarctic settlements (remote notes). The equipment
                                                      in each node is accessible to the rural medical center.
                                                      The central hospitals are connected to the network 24
                                                      hrs/day and the remote nodes login by standard
                                                      telephone lines with modems. With this scheme, a set
                                                      of telemedical events can be developed, including
                                                      teleassistance and tele-education. This program has
                                                      been running since 1998 and to date has carried out
                                                      more than 200 medical events. In addition, CONAE is
                                                      working on technological development of equipment


                                                                                                                        7
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



                                            for use in other tele-medical applications.
Telemedicine                50 Colbee       Using a standard Internet PC with video link, a call
Remote                      Court, Philip,  centre can monitor a remote patient and check blood
Monitoring                  ACT,            pressure, pulse, oximeter, temperature as required. A
                            Australia       patient can have a permanent connection with a
                                            scheduled check or initialise contact with a call
                            http://www.ap centre. Designed to minimise community nursing
                            proved.com.a visits, and allow persons to stay at home under
                            u               supervision instead of out patient clinic, nursing
                                            home, or surgery visit.
Telepsychiatry              7 Field Street, Telepsychiatry is the use of videoconferencing to
Network                     Mount Lawley, improve links with rural and remote populations
                            Perth,          around the state of Western Australia. Some 40 sites
                            Western         located in major and minor service centers as well as
                            Australia,      the state capital allow face to face contacts between
                            Australia       clinicians and consumers. Development of clinical
                            6050            programs continues along with education and many
                                            other functions to support rural and remote staff and
                                            services
A Distributed               East Carolina This project has three components, each of which
Telemedicine                University      involves the implementation of distributed networks
Network for                 School of       (general independent networks) using low cost
Eastern North               Medicine, 1S- technology. The first project involves development of
Carolina                    10 Brody        telehome care in north eastern North Carolina.
                            Bldg.,          Working with a home nursing agency affiliated with a
                            Greenville, NC multi-county health department, POTS based home
                            27858           telecare units are being used in patient's homes. The
                                            second project targets telemental health. Low cost
                            http://www.tele PC-based 128 Kbps ISDN teleconferencing units
                            med.med.ecu. have been placed in the clinics of a multi-county
                            edu/grants.ht   mental health agency to help provide client care and
                            m               network the clients. The third project is a school
                                            based telemedicine network linking all the schools
                                            within a countywide school district and a
                                            paediatrician’s office to provide medical care and
                                            other services to students. Low cost PC-based 128
                                            Kbps ISDN teleconferencing units are used for this
                                            network
Allina Health               5601 Smetana Telemedicine network exists to improve access of
System/Rural                Dr,             specialists to the rural locations, particularly
Health Alliance             Minnetonka,     emergency coverage, to provide continuing education
Telemedicine                MN 55343-       for physicians, nurses, and other providers and
Network                     5010            employees of Allina and Rural Health Alliance (RHA)
                                            hospitals, and to provide videoconferencing to allow
                                            for more convenient 'face-to-face' communication
                                            among employees located at facilities throughout the
                                            network




                                                                                                                        8
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



The Founder of the Medical Computer Society of India (MCSI), which was
launched on the net on September 6, feels that as far as India is concerned,
even though doctors have not really taken advantage of the explosion in
telecom and computer technology, "I think telemedicine is just around the
corner".

Table 4. TELEMEDICINE KNOWN PROJECTS IN India

 Name of Promoter                                                                   Details
the project  s/
          sponsors
PRIVATE Andhra                        The State-run APVVP, which manages nearly 200 hospitals in
– PUBLIC Pradesh                      Andhra Pradesh, has launched the Telemedicine project in the
PARTNER Vaidya                        moth of October 2001 with the collaboration of local private
SHIP     Vidhana                      partners.
THROUG Parishad
H        (APVVP),                     The responsibility of providing the telemedicine-compatible
TELEMED APOLLO                        diagnostic medical equipment such C.T. Scan, ultra sound
ICINE    Hospitals                    scanner, colour Doppler, ECG, digital x-ray, etc., in the district
         , CARE                       hospitals lies with the implementing partners. The implementing
         Foundati                     partners are the major players in terms of running huge hospitals
         on                           networks in cities like Hyderabad. Mostly they connect the
                                      telemedicine systems to their base hospitals in Hyderabad and
                                      other places.

                                      Each of them in tern formed consortiums with software and
                                      hardware companies and at the time of writing this article the
                                      project is operational in Mahabub Nagar district.

                                      The Government has laid down rules for the collection of user
                                      charges as per three categories -- private, subsidised and free
Rajkot              Rajkot             Rajkot Civil Hospital has developed a telemedicine link with U.N.
Civil               Civil              Mehta Institute of Cardiology and Research Centre, Ahmedabad.
Hospital            Hospital
                    and                The system can be used to transmit online ECG, CT scans,
                                       magnetic resonance imaging, Cathlab reports, pathological
                    U.N.               reports, doctors' prescriptions, typed and even handwritten
                    Mehta              notes, and moving images.
                    Institute
                    of                 The important innovation employed in this system is
                    Cardiolog          the Event Recorder (ER). The ER has no cords attached to it.
                    y and              The patient simply has to place it on his chest, push a button and
                    Research           wait for a minute for recording the ECG. This done, he has to dial
                    Centre,            the telephone number of his doctor and place the equipment on
                    Ahmedab            the mouthpiece as per directions given, and press the same
                    ad.                button again. The ER converts the electronic signals into audio
                                       signals which again get converted into electronic signals on the
                                       doctor's personal computer.

                                       The ER was tested on domestic flights, in moving vehicles,


                                                                                                                        9
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



                                       offices and parks. It worked to the satisfaction of medical
                                       experts.




Apollo              Apollo            A 50 bed hospital in Aragonda village (population of 15,000) of
telemedici          group             Chittor district in Andhra Pradesh is connected to the Apollo
ne                                    group main hospitals in Chennai and Hyderabad through a
                                      satellite link. The center is equipped with facilities such as an
                                      operating theatre, a computed –tomography scanner and
                                      software. Doctors the telemedicine center can scan, convert and
                                      send data images via satellite link to the tele-consult stations at
                                      Hyderabad and Chennai.
Narayana                              Narayana Hrudayalaya, located in Bangalore is developing as a
Hrudayala                             hub for telecardiology networks with a joint venture between the
ya                                    governments of seven hill states, Government of West Bengal,
                                      Karnataka Health Systems and ISRO to create a chain of
                                      coronary care units in remote areas and offer modern cardiac
                                      care infrastructure. The communication networks between these
                                      areas will be arranged through VSAT communication provided by
                                      ISRO, free of cost.
                                      The Heart Hospital is created as a social welfare venture where
                                      60 per cent of the beds are reserved for working class families
                                      who will be offered treatment at subsidised rates. The charitable
                                      activities of the institutions is supported by Kiddies Heart
                                      Foundation, Sarojini Damodaran Charitable Trust, Mathrubhumi
                                      Medical Trust, Bagaria Trust, Prime Minister’s Relief Fund, Chief
                                      Minister’s Relief Fund, Health Minister’s Relief Fund, Mithun
                                      Chakraborty’s Amra, Society for Indian Children’s Welfare, Rotary
                                      and Lions Clubs and various other philanthropic organisations.
Pune                The Pune          The Pune district administration has teamed up with
Primary             district          doctoranywhere.com and Tata Council for Community Initiatives
health              administr         (TCCI) to launch a telemedicine service from a government
telemedici          ation             primary healthcare center (PHC). The service, launched at three
ne project                            healthcare centers, is targeted at the rural masses.

                                      There are 88 PHC's in Pune district, each in-charge of five to six
                                      sub-centers. Each PHC has two doctors and basic medical
                                      facilities, including operation theatres, laboratory and a
                                      pharmacy. It also has 15 personnel who travel to the sub-centers
                                      to implement government medical programs.

                                      The telemedicine project, later aims to connect all PHC's in the
                                      district. In the first phase, three in Wagholi, Chakan and Paud
                                      regions would be linked with the district administration of Pune
                                      and the specialists.

                                      There are at least five to six doctors always present at the



                                                                                                                      10
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



                                      headquarters who can respond even if there are no specialists.

                       Ten specialists (two each from each category) have been chosen
                       from dermatology, nephrology, neurology, cardiology and
                       gastroentrology. Doctors at the PHC refer complicated cases to
                       the specialists in major cities who in turn will give their advice
                       within 24 hours.
                       The TCCI has donated three Pentium computers for the project.
                       The district administration will provide computers to other PHC's.
                       The service has started at the PHC's at Hole in Baramati tehsil,
                       Otur in Junnar tehsil and Nirgudsar in Ambegaon tehsil and in
                       another 40 PHC's within a year
Post        Post       The PGI is being connected to three premier institutes including
Graduate    Graduate the All-India Institute of Medical Sciences (AIIMS), Delhi, and the
Institute,  Institute, Sanjay Gandhi Postgraduate Institute, Lucknow. Later the PGI
Chandigar Chandiga will be connected to some more institutes. The introduction of this
h           rh         facility will not only enable the doctors to seek the opinion of
                       experts from across the country but also save patients from the
                       botheration of being referred to other hospitals
Doctorany              Doctoranywhere.com is a service that allows doctors to be
where.co               doctors - anywhere - if you're on the Net. We have created an
m                      Internet based software and hardware package that provides an
                       affordable, efficient and time-sensitive platform for remote
                       medical consultation to take place easily. Whether you are a
                       physician, a specialist, a pharmaceutical representative, an
                       insurance company, a hospital or private clinic, if you are
                       remotely connected to health care in and around India, we can
                       make your life simpler. The website will provide information on
                       the service we provide.
Telemedic Informati The systems was set-up to cater to the emergencies that arise in
ine project on and     a huge fair like Kumbmela. Utilising the ISDN telephone lines
at          broadcas terminals were set up in Allahabad Medical College and Lucknow
Kumbmela ting          and data compression has been used for sending X-ray, ECG,
fair        ministry   pathological slides, text of medical report, snap shot or live video
(temporar in           of the patients to experts sitting in the Sanjay Gandhi Post
y and now associati Graduate Institute of Medical Sciences (SGPGI) Lucknow.
has been    on with
dismantle the Uttar It employed sophisticated encryption technologies to safe guard
d)          Pradesh    the confidentiality of the prescription of the doctors from the
            governm remote terminals.
            ent




                                                                                                                      11
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



Governmental efforts to develop broadband services to the small towns

Andhra Pradesh and Tamilnadu governments have been developing huge
networks based on Fibre optic links, which can district, block and mandal
head quarters.

Andhra Pradesh government has embarked on a huge broad band project
with private consortium. It plans to cover all the vilaiges in Andhra Pradesh
within three years. Each villiage is proposed to be covered with 100 MB and
each mandal with 1 GB connection. How ever though they will use fibre to
connect most of the mandal (small block) they need WIFI and other
technologies to connect to the final village.

The major technologies to be employed are Digital Video Broadcasting (DVB)
using CODECS of Tadiran, Israel, TDMA Satcom of VIASAT, USA with Voice
Over IP products of ARELNET, Israel. BEL will integrate above technologies
into a single platform and provide end to end solution for APNET.

Some of the Indian firms and institutions have developed technologies to help
implement telemedicine links in the country. Table 5.summarizes the selected
firms and their products.




                                                                                                                      12
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




Table 5. Indian firms / organisations that have developed technologies (hardware
software related)
The Centre for        Integrated Telemedicine solution called Mercury.
Development of
Advanced              Doctors will have to create an electronic medical record (EMR) of
Computing (C-         their patients by consolidating relevant clinical data, before they
DAC)                  do tele- consultation with other specialists for diagnosis and the
                      course of treatment.
http://www.cdacind Mercury facilitates these two key aspects of Telemedicine in a
ia.com/html/medinf user-friendly fashion, C-DAC said in its recent internal
o/mercury.asp         publication, C-DAC Connect.
                      With Mercury, doctors can quickly put the patient record, usually
                      available in the hard copy form such as papers, celluloid films
                      and ECG strips, into an EMR and classify them.
                      While data in celluloid films and other hard copies can be
                      scanned in, ECGs and video clips of endoscopies, etc., can be
                      made a part of the EMR using direct interface to the devices.
Apollo                Apollo Desktop Teleconferencing Module
Telemedicine
                      Apollo provides stand alone software with the ADTM so that the
www.apollotelemedicin user may have a desktop teleconferencing system in Windows
e.com                 that can link up with other industry standard compliant video
                      conferencing vendor systems
                      Minimum transmission rate required is 64kbps and maximum is
                      1.54mbps. The transmission speeds recommended for Tele-
                      pathology is 512kbps unrestricted ISDN or T1line. TCP/IP is also
                      a usable format but requires a base WAN connection at T1 speed
                      or faster




                                                                                                                      13
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




Telemedicine                          Integrated telemedicine solution
Research Institute
(OTRI), Ahmedabad                     Using indigenous technology, the institute developed the
                                      system with expert advice from a panel of eminent physicians
                                      and surgeons from India and abroad. It can be used to
                                      transmit online ECG, CT scans, magnetic resonance imaging,
                                      Cathlab reports, pathological reports, doctors' prescriptions,
                                      typed and even handwritten notes, and moving images.

                                      Moving images, which may include X-rays, sonography,
                                      angiography, 2-D echo and colour Doppler, are important in
                                      finding minor clues for precise diagnosis. The specialists can
                                      even get a feel of the patient's heartbeat through an electronic
                                      stethoscope, which could be attached to the computer at the
                                      peripheral health centre.

                                      But the most important innovation is the Event Recorder (ER).
                                      The patient simply has to place it on his chest, push a button
                                      and wait for a minute for recording the ECG. This done, he
                                      has to dial the telephone number of his doctor and place the
                                      equipment on the mouthpiece as per directions given, and
                                      press the same button again. The ER converts the electronic
                                      signals into audio signals, which again get converted into
                                      electronic signals on the doctor's personal computer.

                                      The ER was tested on domestic flights, in moving vehicles,
                                      offices and parks. It worked to the satisfaction of medical
                                      experts.

Siemens Information                   Magic View
Systems Ltd. (SISL), a
joint venture between                 Some of the telemedicine solutions developed by SISL for the
Siemens Ltd., (India)                 medical division of Siemens AG, include Magic View, which
and Siemens Nixdorf                   uses existing local area networks, public telephone lines and
Informations systeme                  PCs to distribute medical images (CAT, MRI, X-ray,
AG, Germany,                          ultrasound) within a hospital as well as to locations outside a
Bangalore                             hospital. This combination of telecom and diagnostic imaging
www.sms.siemens.com/Pr                helps improve the effectiveness and efficiency of health care
essReleases/magvw300.p                by facilitating long distance reporting and remote access to
df
                                      medical fraternity for immediate diagnosis.




                                                                                                                      14
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




Table 6. Choice of communication options available to connect the remote places with
telemedicine
Type of         Its           Features                  Feasibility
connection      deployment
                in India
Dial up over    Employed      Connected with very       Most of the Indian villages
normal          by many       low speeds in remote      (PHC) have telephone
telephone       projects      places and it is          connection. But the line quality
                              possible to transmit low needs to be improved to
                              quality images            sustain a continuous link for
                                                        transmission of data.
ISDN            Employed      It provides reliable      At present not available in
Telephone       by many       connection at higher      small towns and even in most
line            projects      speeds, but relatively    of the district head quarters
                              expensive and user
                              has to pay STD or 2
                              times STD charges
                              depending on the
                              connection speed
VSAT            Employed in High initial set up costs Several permissions from the
Connection      couple of     of 1 million Indian       government are needed and
provided        projects      rupees at the             operational costs are high and
thorugh the                   minimum.                  at least 1 million Rs per year
government                                              and it is only point-to-point
run telephone                                           connection and speeds are not
company                                                 more than 64 kilobits in India.
through
satellite
transponders4.
Wireless wide Not yet         Low initial costs and     Operates in free bands of
area network    employed      high bandwidth for        frequencies and hardly any
model           by any        data and video and        operational costs are involved.
                telemedicine voice channels
                project.




                                                                                                                      15
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




THE ISSUES AND HEAVY COSTS ASSOCIATE WITH THE PRESENT
TELEMEDICINE MODELS IN INDIA.


         Most of the projects are model projects and implemented on a very
          small scale. Their impact and usefulness to the large rural audiences is
          fairly limited and does not even constitute 0.0001 beneficiaries in India.

         Generally the motive behind launching these kinds of model projects is
          to serve the particular specific requirements of an NGO or
          demonstration of technology or gathering some limelight.

         Many of them have been started with a big fanfare and unveiled plans
          to interlink thousands of PHCs in the country and now they are barely
          running the single outfit they have originally commissioned.

         As it is with any technology project, it is very easy to set up by installing
          a set of machines and links, but needs much more motivation to
          sustain them on a continuous basis.

         Except for one or two projects the rest of them aimed at connecting
          one city based hospital with a metropolitan hospital. The rural focus is
          fairy limited to couple of model projects.

         Government which must be encouraging viable models to offset the
          lacunas in the primary care access and coverage problems, has not
          done much and is following the regular route of construction of new
          PHCs and supplying sophisticated equipment. They are oblivious to the
          fact that all these infrastructure developments cannot motivate the
          doctors and Reproductive Health Specialists to the villages.

         Where as dialup models are not effective, the costs and maintenance
          of VSAT based network is prohibitively expensive and requires skills to
          set up and maintain. This hinders the opportunities for business and
          governments to mass replicate the model projects.

         Essentially rural India is not ready with very costly and heavy
          overheads involved present models of telemedicine.




                                                                                                                      16
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



Emerging BROADBAND wireless networking technologies and
opportunities for cheaper networking of rural hospitals

Most of the telemedicine solutions are developed in the west and bandwidth is
the not the issue (except some reservations in America). The solutions tend to
take the issue of connectivity at higher speeds as guaranteed. But in India
even the copper
pair is not properly   Table 7. Typical time taken to transmit a standard X -Ray
available to the
villages. The
importance of                               28.8 Kbps dial-up     30 minutes
bandwidth can be                            connection
gauged by the
                                            T1 line at 1.5 Mbps 30 seconds
table no 7.

At the same time                           DS3 circuit         1 second
the broadband
wireless
technologies that connect wide area networks (WAN) are becoming very
cheap day by day. Today it is possible to connect two computers/networks
with 11 MBPS speeds over 40 KMs without out any bridge/amplifier in
between. 11 MBPS bandwidth means it is possible to stream two way video,
voice, data at a very high quality.

The cost for each wireless client has come down drastically and it is now
around 700 to 800 dollars for a wireless card and the antenna and the
software bundle5. By providing suitable bridges and amplifiers6, (which cost
less than 1000$) the signal can be send to any remote place in a typical
Indian district which generally caters to 1 to 2 million population.

The following sections present the possibilities of developing a cost effective
BROADBAND WIRELESS WIDE AREA NETWORK in a typical Indian district
which consists of 1 district hospital and 5 to 10 other hospitals and 30 to 70
Primary Health Centers.




                                                                                                                      17
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




Need For Reliable Forms Of Communication Between The Peripheral
Institutions Like SHCs And PHCs And Administration and District
Hospital

In the health care delivery mechanism in India, most of the services especially
the reproductive health care services are delivered at the peripheral
institutions like Primary Health
Center. It is a well-known fact that     Alternative VHF based communication systems
                                         and their limited usefulness
smooth and reliable communication
between PHCs to CHC and district         VHF based communication has long been used by
hospital will greatly improve the        the police and other services. Operational costs of
service delivery at the peripheral       those systems are very less and hardly any.
institutions.
                                                               The channels available for communication are very
                                                               less like 2 to three utmost. In the sense the entire
         It becomes easy to monitor                           district will have to use only 2 channels any time.
          the national programs and
          other services from district or                      There is a need for constantly attending the
          block medical head quarters.                         instrument, as the party called has to attend to call.
                                                               It is mostly bi-directional and on talk and listen
                                                               basis.
         Referral services can be
          improved                                             The cost for each installation can be around 15,000
                                                               to 20,000 Rs.
         In the case of emergency
                                                               There is no privacy in the systems and anyone with
          services guidance can be                             a VHF SET or scanner can listen to the
          orally sought through                                conversation and block if he can.
          telephone or radio means of
          communication.

The system that is proposed in this article has enormous benefits in terms of
revolutionising the

    Referral services,
    Tele-medicine
    Tele training,
    Voice communication
    Data transfer and
    Desktop Video conferencing




                                                                                                                      18
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



The features seem a bit incredible but, the technology is now available and
very effectively implemented in the industry and services sector in the
developed countries. It is basically used to distribute Internet services or
connect far off places (without cables and digging etc)


  Basically the central unit can be located in the district hospital on a small 3 to 4
  computer network with each computer having a video camera. PHCs and CHCs
  are connected through the wireless network cards of a desktop computer,
  which houses a small video camera. Briefly the features are explained below.

           It provides for two ways or multiple broadcast video conferencing on a
            desk top computer which can be put to other uses.

           As many telephones in each hospital/PHC/CHCs can be connected to
            the system and called can be made with in the network for free.

           A PHC can communicate or video conference with any other hospital
            or PHC/CHC/ HOSPITAL in the district or vice-versa. If interconnected
            two or more districts can exange data video etc.

           A patient attending an X PHC/CHC can be examined by any specialist
            in the entire district through video conferencing.

           Doctors can monitor any operation or procedure remotely from any
            location in the district.

           Online video broad cast can be made from the district or any facility
            enabling the training and conferencing.

           It is totally confidential and it is almost impossible for any
            eavesdropping or tampering the system.

           Any micro wave communication requires line of sight and in case line of
            sight is not available suitable bridge has to be provided at a higher
            location.




                                                                                                                      19
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




     Figure 1. Thematic example of SAMPLE DISTRICT IMPLEMENTATION




                                                                                                                      20
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



WIRELESS WIDE AREA NETWORK – TECHNOLOGY EXPLAINED

The technology proposed is                               Broadband fixed wireless
called Direct Sequence Spread
Spectrum technology and it                               Broadband refers to communications with sufficient
                                                         bandwidth to handle multiple services, such as voice, data
works in the frequency like ISM                          and video. Generally, this requires T1 (1.5 Mb) and above
BAND 2.4 or 5.2 or 5.7 GHz.                              although this term has been applied to any end-user
                                                         connection with more that a single VF (64 kb) capacity.
                                                         Fixed wireless is a reliable method of connecting fixed
Low power and high gain
                                                         locations, such as offices or buildings with a radio link.
antennas will be utilised to
transmit and receive. There may                          Advantages of wireless over copper or fiber connections?
be a need for repeaters and
                                                         Wireless is immediately available with no right-of-way
bridges in case of big                                   limitations. License-free frequencies are available to any
obstructions like hills and others                       service provider, and licensed frequencies may also be
in hilly districts. Basically the                        obtained by end users or carriers. Copper and fiber
computers in all hospitals                               connections usually require monthly leased line fees paid to
                                                         telephone companies whereas service providers can own
become a wide area network with                          and operate their own wireless infrastructure. As a result,
each having their own IPs.                               wireless systems enjoy lower cost, and often higher
                                                         reliability, than copper or fiber.
The available hardware is IEEE
                                       Range of a wireless links
802.11 compliant Wired
Equivalent (IEEE 802.11 is the         Maximum typical distances range from 5 KMs to more than
new standard for wireless LANs)        50 KMs line-of-sight, depending on the antenna system,
64-bit data encryption is              frequency and capacity selected. By employing a bridge
                                       amplifier the range can be extended by another 50 KMs.
employed using 5-digit encryption
keys (RC4 algorithm). 128-bit key      Need for line of sight connection
encryption may also be
employed. Standard security            For a reliable connection at microwave frequencies there is
                                       a need for line of sight connection.
features protect the sensitive
data using four levels of
integrated security to protect the network from unauthorized access.

1) Direct Sequence Spread Spectrum technology
2) Network Identification Code
3) Access Control
4) Data Encryption.

.




                                                                                                                      21
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




          Figure 2. Flow chart of patient examination by telemedicine in a
          model district (only few hospitals are shown)




                          A patient
                          from a village
                          visits the
                          PHC

                                                                                                     Hospital 2

                                             She puts the
                                             patient to the
       The attendant                         general doctor
       Nurse takes her                       /specialist at the
       pulse and other                       district hospital
       oral examination                      (usually the link is
                                             always on)


                                  10 MBPS wireless and video link
                                  operating on 2.4 GHz

                                                                      10 MBPS wireless and video
                                                                      link operating on 2.4 GHz
                                                                                              In case needed
                                                                                              the patient can
                                             Doctor examines                                  be put to any
                                             the patient on the
                                                                                              doctor in other
                                             video and checks                                 hospital
                                             his pulse and can
                                             consult a                                                            Hospital 3
                                             specialist in the
                                             same hospital
                                             and prescribe                       It takes not more than 10 minutes
                                             medicines etc                       to get any expert advise at the
                                                                                 remote PHC

                                                                                 The interactive video can be
                                                                                 recorded for further analysis
                                                                    District
                                                                    Hospital




                                                                                                                               22
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers



Table 8. Cost estimate for one sample district

ITEM                                          UNITS            COST US            TOTAL in US $
                                                               $
Base station with 2                           1                4000               4000
computers, transmitter,
video etc
Clients (all CHCs and                         50               1500               75,000
PHCs)
Bridges and repeaters                         5                1500               7500
Sub- total                                                                        86,500

Installation 10% of the                                                           8,650
above
Total                                                                             95,150



In summary one can network a district, which caters to 2 million
populations with less than US $ 100,000, and provide for real time video
and data and voice interaction with one hospital with any other hospital.

The above budget covering 50 hospitals is equilent to setting up two
traditional telemedicine centers with VSATs etc. Operational costs for this
model are hardly any it is around 5 % of the installation costs. Since the
network is self owned there are no payments for voice, data or video as it is
the case with VSAT and other solutions. In few minutes a patient can be
referred to any specialist in the entire district and examination can be
conducted. To start with, only minimal equipment interfaces like (digital
stethoscope) can be provided and as the usage increases and skills increase
more and more devises can be connected to the computer and to the
network.

The cost of the model is very low and other satellite models through VSAT
linking stand no comparison in terms of cost, efficiency ease of set up and
operational cost and finally bandwidth. It is equilent to maintaining just two
small hospitals in terms of salaries and          Major vendors working in the
other expenditures. (Matrix no. 1 clarifies       hardware filed and supplying
the tremendous cost and technical                 wireless modems operating in ISM
                                                  band of 2.4 and 5.2 and 5.7 GHz.
advantages of the proposed model)
                                                                         CISCO with its Aeronet wireless
                                                                         LAN products.
                                                                         Alvarion, (formerly Breezecom),
In India with the Internet Service Providers                             Cylink,
(ISP) business having matured, there are                                 Gleneyre,
many vendors who have established similar                                P-COM and
                                                                         Wave Span.
links between an ISP and a particular
company/office. This means there are
plenty of qualified manpower, experience and skills available in all parts of the
country.



                                                                                                                      23
       Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
       and primary health care centers




Table 9. Superiority of the proposed model over the conventional methods
Method                Proje      Oper       Band       Initial       Uses          Operatio        Live         connectio          Online     availabi
                      ct         ationa     width      set up                      nal costs       video        ns                 or off     lity
                      cost       l cost     availa     cost                        per year        transmi                         line
                      for a      for an     ble                                                    ssion
                      distric    year
                      t with
                      50
                      hospit
                      als
Dial up over                                Up to      Low in        Limited       Medium          No           Between            Off line   Most of
normal                                      56         the           data                                       two                           the
telephone                                   KBPS       range         and                                        points                        places
                                                                     email
ISDN                  Not                   64 to      Mediu         Data          High            Poor         Between            Off line   Only
Telephone line        availa                384        m             and                           quality      two                and        big
                      ble                   KBPS                     email                                      points             some       cities
                                                                     and                                                           times
                                                                     rarely                                                        online
                                                                     poor
                                                                     quality
                                                                     video
VSAT                  1.25       1milli     64         Very          Data          Very high       No           Between            Online     Any
Connection            millio     on         KBPS       high          and                                        two                           where
provided              n                     at                       rarely                                     points
thorugh the                                 prese                    video
government run                              nt
telephone
company
through satellite
transponders.
Wireless wide         0.1        0.01       Up to      Mediu         Data          Nominal         Yes          Multi              On line    Any
area network          millio     millio     11         m             and                                        point and                     where
                      n          n          MBP                      video                                      broadcas
                                            S                        streami                                    ting
                                                                     ng and                                     mode etc
                                                                     live
                                                                     examin
                                                                     ation




                                                                                                                             24
Revolutionising the primary health care in India through Telemedicine based on WIRELESS WIDE AREA NETWORKING of hospitals
and primary health care centers




Need for efficiency and high end technologies in public health
administration

A serious criticism levelled against the use of computers or any advanced
tools in the government and especially in the health care delivery, is that it
costs a lot. The other observation is that we should supply drugs first. The
views are pushed by a set of people who believe that health care can be
delivered by just pushing some files and posting few staff.

Probably the criticisms are also based on a notion that computers are very
expensive, difficult to learn and used mainly for word-processing and high-end
calculations. But, today computers are available for less than 400$ in India. It
is true that computers do word processing, but they are designed and will
work better, give optimum results, when they are used to build, and process
huge amounts of data.

Worldwide industries of all sorts innovate, employ latest technologies, borrow
from military and space fields and adapt to their requirements in pursuit of
efficiency, savings and competitive advantage. (As is the present case with
wireless technologies – the wireless spread spectrum technology is adopted
from the military). Unfortunately public health administration word wide and
more so in developing countries lacks vision and innovative ability.

It is not the number of employees that decides the quality of service but their
efficiency. In public health, the resources are few, time is extremely limited
(with the threats of outbreak of epidemics like AIDS) and results have to be
achieved in a limited time frame. Therefore, there is need for more and better
tools, and any additional aids makes these tasks easy and efficient. India
spends 85% of the government budget on the personnel and personnel alone.
Employment of additional personnel or creation of one department or a post
will not automatically ensure achievement of the set objectives in improving
the health status of Women and children. Public health is a proactive and
developmental function. The personnel need implements, tools, and training
to effectively discharge their duties.


1
  2001 Census notes - http://www.censusindia.net/results/population.html
2
  Bulletin on rural health statistics in India June 1997, Issued By Rural Health
Division, Directorate General of Health Services Ministry of Health and Family
Welfare Government of India, New Delhi.
3
  Project implementation Plans for improving the secondary infrastructure in
various states through World Bank loans
4
  http://www.aptelecom.gov.in/hvnet.html
5
  http://www.tribecaexpress.com/aironetprice.htm
6
  http://www.tribecaexpress.com/aironetprice.htm




                                                                                                                      25

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:49
posted:7/9/2010
language:English
pages:26
Description: Breezecom Website document sample