India is short of 600,000 doctors, 1 million nurses, and 200,000 dental surgeons to achieve 1:10,000 doctor-patient ratio. According to India’s Planning Commission, nearly 72 percent of India’s population still live in villages where healthcare facilities are poor. Eighty percent of doctors in India, 75 percent of dispensaries, and 60 percent of hospitals are situated in urban areas.
Rashtriya Swasthya Bima Yojana (RSBY) is a national health insurance scheme launched by the Government of India. Under this scheme, families below the poverty line can be covered (up to five members) for Rs 30,000 (about $600) per year. The insurance premium is paid by the government, covering approximately 30 percent of India’s population.HOME CLINIC
The idea of being treated from one’s home is very comforting and is proving to be cost-effective. Driven by the aging population, the increased medical requirements in remote locations, and the recent advancements in technology, the world market for telemedicine is forecast to reach $18 billion by 2015 (Source: Global Industry Analysts Inc.). Hence, telemedicine will soon play a very important role in our lives.
There are different forms and use-cases of telemedicine based on the type of service:
> Teleradiology: Provides primary diagnosis of medical images like X-ray by a radiologist.
> Teleconsultation: General practitioner consultation through an audio-video conference and exchange of patient information for routine chronic disease management (like diabetes, high blood pressure, etc.), non-emergency review, and prescription refills. Used in home, geriatrics, mental healthcare, health kiosks, etc.
> Telecardiology: Observation of a chronic heart patient through monitoring of blood pressure, electrocardiograms (ECG), pulse, etc. A cardiologist can review the data and advice on the condition and initiate any emergency care if required.
> Teledermatology: Remote diagnosis of a patient’s skin condition.
> Teleophthalmology: Remote ophthalmology consultations and diagnosis of various eye conditions.
> Telepathology: Viewing laboratory specimens located at a remote laboratory through a camera-based microscope.
Various sensor devices are used in telemedicine applications. These include temperature sensors, blood pressure monitors, weighing machines, pulse oximeter (SPO2), ECG, etc.
AFFORDABLE TELECOMMUNICATION TECHNOLOGY
One of the key considerations in the telemedicine space is to require a reliable and cheap telecommunication technology. In India, broadband installations have grown almost three times in the last year. In remote, inaccessible places, both government and non-government organizations are taking lead by sponsoring satellite links.
For example, the Indian Space Research Organization (ISRO) provides mobile VSAT link through their satellites, connecting the remote regions to doctors. With these advancements, primary healthcare can easily reach millions of patients. Today, bandwidth availability is not a big challenge for other telemedicine disciplines involving images.
To transfer patient information to the hospital server, applications have to be HL7 (health level seven) compliant. Being HL7 compliant, patient health records can be electronically maintained (electronic medical record – EMR). It also allows for sharing of patient data across hospitals and systems, allowing interoperability of applications and systems. In addition, telemedicine solutions should allow for billing and connection to insurance systems. Under the RSBY healthcare scheme, the government has mandated that every person who is availing of the RSBY facility be issued a smart card that would track his/her vital health statistics and insurance cover utilization. Through the smart card, the insurance company can track utilization of the insurance coverage for billing.
COMPLIANCE
Deploying telemedicine solutions in developed countries require compliance with the Health Industry Portability and Accountability Act (HIPAA) to address security and privacy issues of health records. This would mean that patient data has to be secure while at rest (stored in the telemedicine box) and while on the move (transmitted from box to a server or doctor).
For images to be stored or transferred to the hospital server or doctor’s office, the boxes also should be DICOM (digital image and communication) compliant.
IMPLEMENTATION CHALLENGES
Some of the challenges that might be encountered in implementing telemedicine solution:
> Equipment usage: Should be extremely user friendly as availability of a technician at remote location is not feasible.
> Broadband bandwidth availability: Dynamic data throttling for teleconsultation versus image transmission.
> Interoperability and standards compliance: As adoption of standards like HL7, DICOM and HIPAA become more prevalent in developing countries, telemedicine equipment should allow for upgrades without additional investment. Integration and interoperability between existing hospital applications could be a challenge.
> Billing and accounting for the healthcare service: Integration of government scheme and payment to service providers and hospitals could be a challenge.
A telemedicine solution today comprises of a PC for Internet connectivity and data transfer, a web camera for video, an aggregator box to take sensor inputs, and a telephone for audio. Many a times these devices become an impediment in implementing telemedicine solutions in a developing country like India. The different devices needed to make telemedicine work can be expensive and require usage awareness among healthcare professionals. An integrated embedded solution becomes essential for market penetration and adaptability.
SINGLE, INTEGRATED PLATFORM
The MindTree telemedicine platform is a single, integrated aggregator box solution. A variety of sensor devices can be connected to the box through the available USB or serial ports. Audio/video conferencing facility and Internet connectivity are also integrated into the box.
This integrated solution enables the solution provider to configure the telemedicine setup with different sensors and interface devices based on the actual need of the community, thereby significantly reducing cost. It offers multiple variations of the platform. Variants can have smart card readers to address the RSBY requirement, built-in LCD/external monitor/TV, and Bluetooth connectivity. The solution also supports HL7, DICOM and HIPAA standards.
The platform is designed on a standard SoC which supports two processor cores – an ARM core for application software and a DSP core for signal processing. The solution used open source software components to keep the product cost low. Application management is based on Linux operating system (OS).
H.264 compression is used for video, which is an excellent choice as it enables more effective video compression than older standards. H.264 provides better flexibility for applications to operate in a wide variety of network environments, particularly considering the different use case scenarios of the telemedicine solution.
Video is transmitted to the remote side using common intermediate format (CIF), which allows to easily convert to PAL or NTSC format. Also, depending on the available bandwidth, the application is able to throttle and tune the number of frames sent per second. The image type can be changed to quarter CIF (QCIF) if required.
The DSP core in the SoC is used for audio and video conferencing and data processing requirements. The telemedicine solution employs G.711 for audio compression. This is a simple and effective compression algorithm that is used in telephony applications.
By hosting the application and platform on a Linux OS, the telemedicine platform has the advantage of connecting the hardware directly to any IP (Internet Protocol) port without having to worry about porting the TCP/IP protocol stack to the embedded platform. Linux also gives us lot of flexibility in implementing application Graphical User Interface (GUI) using any of the open GUI frameworks.
The platform is also designed to support online firmware/application upgrades. This feature is helpful when new medical standards are evolving, as it eliminates the need for a technician to visit the field and allows easier software maintenance.
The platform handles close to 3,000 patient records. This is adequate for a community of people in a small village. The solution has been realized with low-cost memory devices and interfaces, allowing for optional higher memory size. Patient records are stored as EMRs so as to enable transfer of data to a remote server located at hospitals or data centers. Patient EMR and usage information can be uploaded into the integrated smart card device for tracking and billing purposes. Data is sent to the servers in HL7 format with additional encryption, making it HIPAA-compliant.
BLUETOOTH CONNECTIVITY
Many of the sensor devices like blood glucometers, BP monitors and other personal care devices are becoming Bluetooth-enabled. The addition of Bluetooth connectivity along with the health device profile (HDP) into the platform makes MindTree’s telemedicine solution the perfect equipment for homecare and chronic disease management.
With so much promise in telemedicine, the only challenge left is the acceptance from the patient and doctor community. Moving forward, home healthcare needs to be taken beyond pilot activities and into the main stream. Telemedicine could enable increased life expectancy, better lifestyle, and optimum use of healthcare resources.
SIDEBAR:
Telemedicine definition as per the American Telemedicine Association
Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Closely associated with telemedicine is the term “telehealth,” which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth.
Click here for the illustrations: Figure 1 |
