Role of Telemedicine in Primary Healthcare and
Practical Aspects of Setting Up a Telemedicine Centre

MANU MANAMEL, ARIJIT SARKAR

Introduction to Telemedicine

Manu Manamel has a degree in medicine from the Government Medical College, Thiruvananthapuram, and a Masters in Medical Science and Technology from the Indian Institute of Technology, Kharagpur. He was amongst the top 20 students admitted into the Indian Institute of Managament, Ahmedabad, and nominated for several prestigious scholarship programs. Manu served at JO-AN’s Medical Centre, a 20-bedded pediatric hospital, and was also an Assistant Surgeon in a primary health centre in Rayamangalam in rural Kerala. Manu has held several positions of responsibility and performed duties as WHO’s monitor for the National Pulse Polio Immunization Programme in the Pathanamthitta district of Kerala and as an Executive Member of the House Surgeons’ Council at the Govt Medical College, Thiruvananthapuram.

Arijit Sarkar is Vice-President, Health Care Solutions at ICTPH. His primary interest is to invest in and provide support to socially relevant and sustainable business models, with a particular focus on nascent and early stage entrepreneurships. He has two years of financial modelling experience. His previous role was that of a quantitative research associate at Lehman Brothers, where he built models of liquidity in public equity markets. He has a bachelor’s degree in Electrical Engineering from IIT Bombay.

What is telemedicine?

WHO has defined telemedicine as “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities”.

Along with telemedicine, a number of other terminologies which are connected to telemedicine and healthcare have also gained prominence in today’s world.

The WHO definition for eHealth is “The use, in health sector, of digital data – transmitted, stored and retrieved – in support of healthcare both at the local site and at a distance”.

Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education and training, public health and health administration.

A telemedicine network is an integrated healthcare network that uses modern telecommunication and information technologies to provide comprehensive healthcare services to a specific group.

Teletreatment is the treatment provided to the patient through telemedicine.

Telemedicine system consists of an interface between hardware, software and communication channel to eventually bridge two geographical locations to exchange information and enable teleconsultancy between two locations.

Telediagnostics is the use of information and communications technologies to enable the diagnosis of a patient between geographically separated individuals

Why is telemedicine needed in India?

The most compelling reason for the recommendation of widespread use of telemedicine is the inequitable distribution of qualified medical practitioners. The ratio of allopathic doctors to population is 1:1722 as per the survey conducted by the Medical Council of India(1). 75% of doctors practise in urban areas and 23% in semi-urban areas while 70% of the patients hail from the rural areas. The number of hospital beds available per 1000 population is 2.2 in urban areas while it is only 0.19 in rural areas (Report of the Technical Working Group on Telemedicine Standardization). This represents the gross inequality in the distribution of healthcare services between the urban and rural areas. To project the gravity of the situation in real life, let us take the case of Chennai. Chennai has at least 20 hospitals which can offer renal transplant while many cities don’t have even a single hospital which can perform it. Chennai alone has more neurosurgeons than the entire north-eastern states put together.

As the physicians’ services are inadequately available in rural areas, the rural inhabitants often have to depend on quacks, who are not qualified to diagnose diseases or prescribe medicines.

Employing telemedicine is one of the best options for delivery of healthcare services in distant and remote areas. It is more economical and cost effective to link remote and rural places with a telecommunications link than to physically send the doctors to these places.

Types of telemedicine

Telemedicine can be classified based on the following criteria.

• On the basis of specialty.

• On the basis of timeframe.

On the basis of timeframe

The most widely practised classification is based on the timeframe. Real-time (synchronous) telemedicine transfers the patient data to the receiver end as soon as it is acquired. This is the most widely used method of telemedicine. It could be as simple as a phone call or as complex as a robotic surgery. It requires the simultaneous presence of both the parties and the existence of a fail-proof communication link. Videoconferencing is one of the most widely used synchronous telemedicine units. Other peripheral electronic or PC-based devices can also effectively aid in patient examination, e.g. tele-otoscope, tele-stethoscope.

“Store and forward” telemedicine is asynchronous, and involves capturing the patient data, storing the data and transferring it whenever convenient, to be assessed later offline. It does not require the simultaneous presence of both the parties. A well-structured electronic medical record has to be integrated well to facilitate the transfer.

On the basis of specialty

Tele radiology, tele surgery, tele dermatology and tele ophthalmology were the specialties that utilized the services of telemedicine conventionally. Majority of the diagnoses could be made by visualizing the images of the patient and the lesions. This is why these specialties got a preference over the rest. Nowadays, the benefits of telemedicine are being extended to other specialties such as pathology, psychiatry and cardiology.

Drawbacks of telemedicine

Telemedicine has some inherent drawbacks associated with the process itself.

• The emotional relationship between the patient and the doctor breaks down.

• Loss of rapport amongst the consultants themselves.

• Bureaucratic and organizational difficulties.

• The quality of the information transmitted may decrease or the information itself may become distorted.

• Issues regarding the privacy and safe storage of the health information of the patient.

The infrastructure for a telemedicine centre

The hardware for a telemedicine centre would comprise of the following.

• Information Technology (IT) equipment.

• Medical devices.

• Videoconferencing equipment.

• Telecommunication equipment.

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IT equipment

IT hardware comprises of those equipment that help in connecting to the medical devices, running the software, storing the data and transmitting the data. This includes the computers along with the necessary software to run the computer and the medical devices, the multimedia devices and the security devices. The specifics of the equipment are elaborated in the next section.

Medical diagnostic equipment

This comprises all the medical equipment that would help in making a diagnosis of the pathological condition. The selection of these equipment for each centre has to be made after carefully analyzing the utility that the infrastructure would bring into the functioning of the centre.

The list could contain numerous equipment but the commonly used ones are the following.

• 12 lead ECG

• Glucometer

• Sphygmomanometer

• Stethoscope

• Digital microscope

• Pulseoxymeter

• Spirometer

• Skin camera

• Doppler ultrasound

• Foetal heart rate monitor

• X Ray machine

• Electronic fundoscope

• Otoscope

Each of these equipment must follow the standards that have been laid down for the medical equipment. Some of the other considerations are running costs, interface options, cost effectiveness, customer service and maintenance, etc.

Videoconferencing equipment

These equipment facilitate the two way video and audio conferencing.

Telecommunication equipment

These equipment facilitate the communication link between the centres and include the VSATs, modems, switches, routers and cabling.

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