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

MANU MANAMEL, ARIJIT SARKAR

Standards and Protocols

Key objectives in defining the standards

  • To define the processes for scientific operation of telemedicine in India.
  • To define the telemedicine technology that is suitable and appropriate in Indian context.
  • To identify mechanisms for safeguarding the privacy of every person’s health data.
  • To improve standards of healthcare delivery as telemedicine can be used as a channel to access the experts leading to better prognosis.
  • To improve the availability of quality healthcare services to those who actually need them.
  • To provide a structural framework for interoperability and scalability of telemedicine practices in international environments as well.
  • To contribute to the international community in understanding the legal, scientific and ethical aspects of use of telemedicine.

Need for standardization

The progress that telemedicine has made in the last few years and the enormous potential it possesses to improve the lives of humans would be made redundant if the telemedicine networks are not scalable, interoperable or compatible with each other. Hence there is a need for standardization of the telemedicine practices in the country. The benefits of progress made have to reach even the remotest corner of the country.

Apart from the technical guidelines, there is also a need for the clinical protocol. The clinical protocols would include the scheduling procedures, the equipment operating procedures and the consulting procedures. The clinical technical standards would define the technical benchmarks that are necessary for the clinician to make the diagnosis with reasonable accuracy.

Framework in defining the guidelines and standards

  • Interoperability – The telemedicine networks must be capable of interfacing together and run applications on different systems.
  • Scalability – Equipment/devices that are used for telemedicine to be upgraded periodically as add-on features.
  • Reliability – The equipment should guarantee good performance with minimum downtime.
  • Compatibility – The ability of the devices of different versions or different brands to be interconnected.
  • Portability – The data generated on one system should be transferred to a different system with minimal effort.

Scope of the standards

I. Infrastructure

This includes all the necessary required standards for all the software and the hardware used in a telemedicine
set-up.

a) Hardware

  • Telemedicine platform – This includes the minimum standards that have to be kept in mind when the telemedicine platform is being set up and includes the processor speed, memory requirement, interfaces and peripherals.
  • Clinical devices – This includes the standards that have to be followed while setting up the devices that are integrated with the telemedicine set-up and also includes the specifications for devices that measure the parameters, imaging devices and the compression standards.
  • Videoconferencing units – This specifies the technical requirements of the videoconferencing units including the data rate, picture resolution, frame rate and quality of camera.
  • Communication devices – This includes all the specifications for the communication hardware that connects the telemedicine set-up with the communication links and further includes the terrestrial as well as the wireless networks.

b) Software

  • Operating system.
  • Licensed telemedicine software.

c) Connectivity

  • ISDN
  • VSAT
  • PSTN
  • Leased Line
  • WAN/Wireless LAN

II. Data interchange/exchange standards and minimum data sets (MDS)

a) Identifiers

Identifiers should be unique, universal and standardized for every particular healthcare provider, patient and telemedicine centre to facilitate easy exchange of information within programmes or across programmes. This would also permit easier upgradation of databases, common billing format and faster processing of claims.

Standards

The telemedicine centres are classified into three.

  • Primary telemedicine centre (PTC)
  • Secondary telemedicine centre (STC)
  • Tertiary telemedicine centre (TTC)

Each of these is further divided into L1, L2 and L3 except for TTC where only L1 and L2 exist. L1 is the lowest level on the infrastructure and facilities while L3 is the highest. PTC’s are based out of primary health centre, STC out of secondary centre and TTC out of the tertiary care centres.

1. Telemedicine platform

The hardware platform usually consists of a desktop PC although any of the following can be used.

  • Desktop PC – It provides the maximum flexibility from the perspective of adding a new clinical device, attachment of peripherals and upgradation of memory. For specifications on the desktop, refer Annexure I.
  • Laptop – Laptop gives almost the same features as a desktop PC.
  • Palmtop – This is a suitable option for a portable telemedicine system. The options for interfaces are quite limited.
  • Personal Digital Assistant – This is a smaller version of the handheld computer with limited options.
  • Dedicated Set Top Box – This system is usually used to monitor a patient at home from the consultant’s room. It can support 2-way audio and low-end videoconferencing. It usually operates over PSTN lines.

2. Clinical devices

For specifications of each of the following devices, please refer Annexure II.

3. Videoconferencing units

The videoconferencing units usually have one of the following configurations

  • The unit works as a standalone box with interfaces to the display, microphone and camera. This unit can work as an independent system and provides high quality images. The speed can be raised to as high as 2 Mbps. The unit comes with additional audio and video inputs and outputs.
  • PC add-on card which is plugged in the telemedicine system. The CCD camera and the microphone are connected externally. It can provide a bandwidth of upto 768 Kbps and is less costly than the former set-up.
  • The third type is a camera with inbuilt encoder and the accompanying software for decoding. This equipment is less costly but the quality is also poor. The camera-encoder is connected to a computer, which displays the pictures, by an USB port and cannot function as an independent unit. It can support a bandwidth of upto 512 Kbps though 384 Kbps is the typical strength.
  • Web camera-based videoconferencing over the desktop PC is a very economical method.

For specifications of individual set-up please refer to Annexure III.

4. Communication hardware

The communication hardware provides the connectivity required for the transfer of data and images.

They are classified into two categories:

  • For terrestrial network.
  • For wireless/satellite network.

For terrestrial network:

These hardwares further classified into three.

a) PSTN/POTS

b) ISDN

c) LAN

a) PSTN/POTS – The PSTN link is present almost everywhere and is cost effective. The disadvantage is that it can transfer data only at a very low bit rate. Therefore it is not suited for the transfer of images which are usually large and bulky. A line modem is needed to connect to the PSTN link.

b) ISDN – ISDN lines are used when there is a need for a faster data transfer using terrestrial lines. Though it is faster than PSTN, it is not as effective as satellite link. Almost all the major cities are connected by ISDN link. The interface to the ISDN line is available as a PC add-on card or a stand alone unit.

c) LAN – LAN is required for quick transfer of data between different telemedicine systems within a hospital. It facilitates high speed data exchange across the systems. An additional hardware known as the Network Interface Card (NIC) is required to connect to the LAN. It is either mounted on the PC’s motherboard or is available as an add-on card.

For Wireless/Satellite Network:

a) Satellite Connectivity - This is the best option to connect to remote and far-fetched locations. Though costly, it provides high and flexible bandwidth.

VSAT – Using a VSAT (Very Small Aperture Terminal) is the easiest way to be connected to a satellite link. A 10 Base-T LAN/ Ethernet interface is accepted by the VSAT hardware. (Exact specifications are provided.)

b) Wireless LAN – Wireless LAN facilitates high speed information exchange between the telemedicine networks within the hospital. It requires a specific hardware commonly known as the Access Point (IEEE 802.11 series) which is usually mounted on the walls. The PCs also require IEEE 802.11 series PCI cards to connect to the wireless network.

c) CDMA – Code Division Multiple Access (CDMA) technology is used when it is required to transfer information between 2 telemedicine systems when on the move. This link is capable of transferring data at 128 Kbps. It requires a CDMA phone linked to serial/USB interface of the PC. CDMA is utilized in ambulances to transfer vital information about the patient to the hospital and also by the doctors to monitor patients when on the move. CDMA has the potential to make information available anytime without restriction on mobility.

d) GSM/GPRS/3G Networks – These networks can also transfer information when on the move. The speed is usually > 9.6 Kbps but 3G networks can provide a speed of upto 1 Mbps.

For specifications of each modem, please refer to Annexure IV.

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