Quest for e-health

Consulting a doctor without visiting hospital sounds far-fetched. But this dream is likely to be realised as computers and telecommunication technology are being introduced in the field of health. DR. UMA KRISHNASWAMY on the developing situation.

AGAINST the background of Aircel, Dishnet DSL and Reliance - WorldTel aiming to bring broad band services through fibreoptic networks, it is not surprising that the Government of Tamil Nadu wishes to utilise computer and communication technology in the field of health, to impact favourably on the life of the common man.

In a developing country, the health care challenge lies in ensuring the percolation of quality health care to semi-urban and rural populations, from the tiny citadels of urban medical expertise by a seamless process. Telemedicine has the potential to perform this task more ably and thus profoundly alter the health landscape of the State.

Telemedicine is not new to Tamil Nadu. There have been instances of it in the past within the corporate sector where, for crippling financial reasons, the projects have been left to gather dust and die a natural death when the equipment and software become inevitably obsolete. Today we see a resurgence of Telemedicine, because advances in technology have rendered it significantly less expensive.

In what promises to be an imaginative and bold pilot project, the Government of Tamil Nadu has installed Telemedicine equipment (donated to it by the Medical Centre of Boston International) at The Tamil Nadu Dr. M.G.R. Medical University. which is linked to Kilpauk Medical College Hospital by three ISDN lines and plans are afoot for a second link possibly to a District General Hospital

Telemedicine is the deployment of sophisticated communication technology, by clinicians, to provide medical care to patients from whom they are separated by distance. It is a process of diagnosis, monitoring, treatment and education by moving medical expertise to the patient via a spectrum of technology. It is paradigm shift in the current practice of moving the patient to the geographical locale of medical expertise.

The foundations of Telemedicine were laid by space programmes of the United States and the U.S.S.R. and by the United States Armed Services.

By the use of satellite technology and telemanipulators (master/slave robot systems) linked to high bandwidth telecommunication systems, telesurgery via robotics and telepresence surgery through virtual reality become established in terms of a military (tri-service) and space programme. And we saw the dazzling applications of Telemedicine in the Gulf War, in Bosnia, Somalia and in various United Nations peace keeping operations.

The NASA-Russian Space Bridge Programme allowed the use of Telemedicine in Armenia (after the devastating earthquake) for Post-Disaster Rehabilitation - a typical example of Telemedicine use in International Disaster Response.

Astro telemedicine impacted on Mercury, Vostok, Apollo l, Space Shuttle and Mir and continues to impact on the current international space station programmes, providing a physiological monitoring, prevention and early intervention life-line to astronauts in space.

In contrast to such applications, which to us in the developing countries seems to belong more to the realms of science fiction than reality, the bulk of Telemedicine practised around the world today fortunately does not require such ultra sophisticated technology.

The spectrum of technologies used in our every day world of hospitals and clinics includes: data, still image, motion picture, audio and video transmission through data acquisition, presentation, storage and retrieval systems transmitting bits of information in real time or near real time through a variety of wired or wireless networks, which link the participating, but geographically distant sites.

The popular communications lines ranging from high to low bandwith include:

POTS: Plain Old Telephone Systemlines (data transmission rate 56 kbps), with Digital Subscriber Line (DSL) technology boosting the transmission rates.

ISDN: Integrated Services Digital Network (data transmission rate of 384 kbps).

T-Carrier: T-1, fractional T-1, Multiplexed (data transmission rate of T-1 is 1.554 mbps).

Microwave and satellite links: (data transmission rate in gigabits) .

Two types of technology are used for practical application today:

Store and Forward: Here images are captured by a digital camera, stored and then forwarded along with data to another location. This technology is ideal for non-emergency medical situations where consultation, diagnosis and treatment can wait for 24 - 48 hours, such as in Telepathology or Teledermatology.

IATV (Two-way interactive TV): In emergency medical situations such as a trauma service, video-conferencing equipment at both ends allows real time or near real time consultation. A key feature of Telemedicine equipment which distinguishes it from simple video conferencing units is the use of peripheral devices: electronic versions of examination tools such as stethoscopes which allow the distant cardiologist to listen to the heart of the patient.

There are some crucial issues arising from the technology:

Implications of bandwidth: Clarity of video which carries crucial diagnostic imaging implications requires 10 - 20 (ideally 30) frames per second and this, in turn, requires broad bandwidth for transmission which is neither choppy or delayed. A bandwidth of 384 kbps is usually acceptable, providing 15 fps. Increase in bandwidth above these levels (1 - 2 mbps) does improve clarity, but this may not necessarily translate to a significant improvement in diagnostic accuracy, nor is it cost effective. Lower bandwidths also carry the disadvantage of increased transfer time for images. For instance, a simple image such as an x-ray has a transfer time of 10 - 20 minutes in a POTS line, but only two minutes in a 1/2 T-1 line.

Implications of compression: Compression techniques allow data and images to be transferred through narrow bandwidth, which are less expensive. Current compression rates for data are about15:1 and with the new wavelet compression it is 30:1. Image compression quality is dependent on the quality of the original image and the degree of compression. The latter can produce either "lossless" or "lossy" algorithms. For still images a 10:1 compression using the JPEG algorithm may be acceptable. Ironically, interactive systems may have difficulty achieving good still image quality.

With bandwidth, the mantra is "one cannot have too much bandwidth", but with compression it is "one must not have too much compression". With images, even the loss of a few pixels can have dangerous implications on diagnostic accuracy. So much so that the American College of Radiologists has set the diagnostic standard at 2K x 2K (lines x pixels). At this level, the telemedical film is equivalent to a conventional analogue film and is hence "safe" for interpretation.

Cost: In any Telemedicine programme, hardware, software, network and recurring network access charges are usually the most expensive components. Such equipment ($500,000 and above) requires high volumes of usage, which may well be impossible in the initial phase of any Telemedicine project.

Applications: The primary application of Telemedicine is the creation of a sophisticated portal of access to specialist medical advice for the populace at no or nominal cost (with government subsidy), utilising the relatively small group of specialists available in urban locations.

In the future, it will become possible for a poor farmer, in say Thanjavur district, to obtain a critical consultation from a specialist in a tertiary care institution such as Kilpauk Medical College Hospital without undertaking an expensive journey to Chennai. This means accessibility to standard health care for both the "have's" and the "have - nots", populations in underserved areas (e.g. rural Dharmapuri) or for geographically dispersed populations (e.g. Andaman and Nicobar islands).

This feature of taking health care to the patient has been applied for home health care in the West, wherein the housebound patient (elderly, immobile, physically handicapped, or the chronically ill patient) can stay in constant touch with his doctor or nurse.

In a Telemedicine service, the patient remains under the care of the local primary health care provider (e.g. medical officer in a primary health centre). Interaction with specialists leads to improved local standards of health care in the rural areas. In essence, Telemedicine serves as an informal continuing medical education programme for medical and para-medical staff and also as a health education medium for patients. The latter has important implications for the development of Telepreventive medicine services.

In the process of professional interaction involving data capture and transfer there is an automatic upgradation of medical documentation into electronic format. This in turn will have a positive impact on clinical governance and clinical audit.

In a more formal educational setting. Telemedicine is a portal for lectures and conferences. Trainees in geographically dispersed medical colleges and hospitals obtain quality interactive education, both in theory and practicals (virtual ward rounds, case discussion, five surgery demonstrations).

Barriers: In developing countries there are three basic barriers to this new paradigm: lack of telecommunication infrastructure, funds and trained medical practioners. It is, however, true that the human factor is the bigger barrier: lack of knowledge and skills in Telemedicine, lack of familiarity or discomfort with technology, lack of acceptance of a change in clinical practice style and the politics that surrounds the changing hierarchy within the members of the Telemedicine team.

Problems: Safety considerations in diagnostic accuracy is an issue that is largely technology dependent and skills dependent. The latter is common to all medical consultations whether conventional or through Telemedicine. If the quality of transmission is poor or incomplete, a physician must be prepared in a routine situation to decline diagnosis and treatment to avoid malpractice liability.

Ensuring privacy of patient information sent across public networks, where it may be "seen", intentionally or otherwise, is another issue to be addressed to avoid public disclosure of private facts. Encryption, packet filtering and electronic scrambling are some of the preventive measures.

The practice of Telemedicine across international borders raises serious legal questions. There is the question of a foreign doctor's locus standi in India, since Section 15 of The Indian Medical Council Act, 1956, confers the right to practice only to those registered under its provisions. And though a doctor in India may obtain information from a colleague in a foreign country, to what extent can he act on therapeutic advice without prejudice to his personal liability to the patient?

Despite issues of screen tension and screen proxemics, it is well established that patient satisfaction tends to be surprisingly high. Some of the reasons for this are: "It is just like being there", avoidance of travel and waiting for appointments, the assurance of having the specialist's undivided attention during the consultation and the continuous involvement of the primary health care provider.

The future: Telemedicine is here to stay, grow and shape health care both on earth and in space. It would be wise to have Telemedicine driven by human clinical needs rather than allow it to be driven by technology. Do we have the wisdom to exploit Telemedicine and make e-health a reality without succumbing to mere technical opportunism or crass commercialism?

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