Healing by wire

The joint effort of Anna University and Apollo Hospitals to set up a telemedicine network shows the way in reaching specialised medicare to rural communities.

WHEN Alexander Graham Bell said, "Watson, come here I want you," on March 20, 1876, he was not only making the first telephone call but holding the first telemedical consultation, without realising it though. Bell had spilt acid on himself accidentally and wanted assistance. Since this unwitting beginning, telemedicine has come a long way, with developments in communication and information technologies making healthcare accessible across distances. Yet in a paradox typical of India, most of the 620-million-strong rural population has barely any access to basic medicare.

Celebrating its silver jubilee in a novel way, the Chennai-based Anna University, with 240 engineering colleges under its fold, set up a telemedicine network linking, to begin with, 35 of its constituent colleges in Tamil Nadu to provide high-quality healthcare to their students and, more important, to the rural communities situated in the vicinity of the colleges. The project plans to use the infrastructure base of the engineering colleges to extend hi-tech medicare to people in remote areas.

A joint effort by Anna University and Apollo Hospitals (a pioneer in telemedicine), the project also has the blessings of the Tamil Nadu government. Inaugurating the programme, Chief Minister Jayalalithaa said that this facility, the first of its kind in the country, would bring secondary and tertiary medicare to over 95 per cent of the State's population when all the 240 affiliated colleges were networked. She said: "The world's largest technical university, Anna University, is to show the way to reach specialised medical care to the needy in the remote areas.''

According to Dr. K. Ganapathy, medical director, Department of Telemedicine, Apollo Hospitals, with over 60 per cent of rural India having access to television and with 400,000 villages connected by telephone, telemedicine is the best method to reach basic medicare to remote areas. Where a telephone connection is not available, he suggests the use of wireless technology. Apollo Hospitals plans to set up several hundred telemedicine centres throughout the country using the infrastructure of the nearest engineering college in each case. The Anna University project is a step in that direction.

The project will get more support when the Indian Space Research Organisation (ISRO) puts HealthSat, a satellite dedicated to healthcare, into orbit. In order to reach the benefit of the technology at its command to remote areas, ISRO has provided satellite link to the Andaman and Nicobar Islands, Karnataka, Tripura, Assam, Jammu and Kashmir (Ladakh), Lakshadweep, Orissa and Andhra Pradesh (Sriharikota) to connect with super speciality hospitals in cities.

Called "healing by wire", telemedicine brings high-quality medical care to patients, transcending barriers of geography, distance, time and costs. As the Journal of American Medical Association puts it, telemedicine is "the use of telecommunications to provide medical information and services from simple consultation to performing a surgery. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at facilities in two countries, using video conferencing equipment."

It extends beyond consultancy to transfer of high-resolution medical images such as ultrasound, electrocardiogram (ECG), electroencephalogram (EEG), and X-Ray. The use of a hybrid of television, telecommunications, computer and engineering technologies enables detailed examination even from a distance. Most telemedicine applications require interactive voice and video, as also the Internet facility. Conventional lines can be used with a handset, a computer, a web camera, a monitor and a microscope. The Internet also provides the platform for sending data, text, still images and full motion video.

Telemedicine has been used in some form or the other for the last 30 years. In the 1960s, the National Aeronautics and Space Administration (NASA) of the United States pioneered it, when it started telemonitoring the physiological parameters of astronauts on spacecraft. A major step was taken in 1971, when the Alaska Biomedical Demonstration Project linked 26 sites in the U.S. using NASA's satellite technology.

Telemedicine can be a boon for countries such as India where the majority of the population lives in remote areas without access to even basic healthcare. For, if it wants to create physical infrastructure to cover all the people in the rural areas at current population levels, the government would have to set up 700 hospitals, each with 250 beds. The bed-population ratio is 1:1,333, against the World Health Organisation (WHO) recommended 1:500. Barely 9 per cent of the population is covered by health schemes. The government spends a meagre 0.9 per cent of its gross domestic product (GDP) on health, against the WHO recommended 5 per cent. There are hardly 40,000 specialists 80 per cent of them in urban areas where hardly 20 per cent of the population lives; barely 2 per cent of the specialists serve in rural areas. Also, while 2.2 beds are available per 1,000 people in urban areas, the figure is a meagre 0.19 in the rural areas. With all these problems, telemedicine is probably the answer to "reaching healthcare to all" by 2015 the government's ambitious target.

Telemedicine is a technology-enabled marketing tool as well. It makes it possible for hospitals to address the needs of patients who might otherwise have not used their services. It is increasingly projected by corporate hospitals as a tool for competitive advantage. Several corporate hospitals have set up video conferencing facilities with super speciality hospitals abroad. Tele-surgeries are done routinely now. The two major players in telemedicine in India are Apollo Hospitals and Asia Heart Foundation. Between the two, several remote villages have realised the benefits of technology-enabled medicare.

Apollo Hospitals has 18 telemedicine centres. According to Dr. Ganapathy, Apollo Hospitals' success story in Andhra Pradesh's Aragonda village, 16 km from Chittoor, set the base for the development of telemedicine. This 50-bed hospital offers primary and secondary care to 24 villages covering 48,000 people in the immediate vicinity. It has state-of-the-art diagnostic facilities, including CT scan, ultrasound, echo, and automated laboratory equipment. A paediatrician, a physician and a general surgeon, apart from duty doctors, are based at the hospital.

Started with simple web cameras and ISDN telephone lines, today the hospital has a modern conferencing system and a VSAT (very small aperture terminal) satellite installed by ISRO. Over 200 tele-consultants, specialists in various medical disciplines, are part of this network. With the help of a special software, Mediscope, clinical history and physical findings are transferred from Aragonda. X-ray and ultrasound images are scanned, compressed and sent through ISDN lines. CT images, being DICOM compatible, are transferred to Chennai electronically.

Initially, most of the consultations were off-line and the diagnoses and interpretations were sent to the primary physicians in the rural areas with a small time lag. While there is no fixed time for consultations, a medical officer is present at the telemedicine unit from 9 a.m. until 5 p.m. Emergency consultations are also done. When a teleconsultant wants to discuss the case with the primary physician, a `net meeting' or video conferencing is arranged. All such online interactions are recorded and stored.

Detailed clinical examinations for pseudo seizures, involuntary movements, Parkinsonism, myopathy and so on are done routinely. Electronic digital stethoscope enables auscultation of the heart and lungs. Several serious head injuries were managed successfully with telemedicine in villages around Aragonda. Tertiary care has also been possible in remote villages with such a facility. Apollo Hospitals has set up telemedicine centres in Karim Nagar (Andhra Pradesh), Kohima (Nagaland), Port Blair (Andaman and Nicobar Islands), Silchar (Assam), Madurai (Tamil Nadu), Mysore (Karnataka), Kolkata and Burdwan (West Bengal), and Panaji (Goa) and the Military Hospital in Chennai. These are all connected to the tertiary care Apollo Hospitals in Chennai, Hyderabad and Delhi.

In the second phase of the project, Apollo Hospitals is to cover 125 primary, 25 secondary and three tertiary centres in Maharashtra, Gujarat, Madhya Pradesh, Tamil Nadu and Andhra Pradesh. The third phase will connect 2,500 primary, 500 secondary and 100 tertiary centres all over the country. Apollo Hospitals also plans to connect international centres of medical excellence with local medical institutions.

On the flip side of Apollo Hospitals' success are issues that need serious attention if telemedicine is to be used widely. According to Dr. Saji Salam, head of healthcare and lifesciences practice, Vmoksha Technologies, connectivity is a major problem as many remote areas do not have basic telephony. The high cost and the poor quality of Internet/telephone services, extremely low penetration rate in rural areas, low literacy levels and so on are some of the issues that need serious attention. The idea of an exclusive satellite from ISRO to service healthcare needs is a revolutionary one and would go a long way in connecting remote areas.

As telemedicine spreads, adhering to standards, as also maintaining security and privacy, would be a challenge. A major concern is with respect to legal and regulatory measures. Questions that need to be addressed are: Who is responsible if telemedicine-assisted surgery fails owing to failure in connectivity? Is it the surgeon, the satellite provider or the software/hardware engineer? What is the legal status of telemedicine-based diagnosis and treatment? Other legal issues that need attention are conflicting national laws and information piracy. There are also the dangers of prescription drugs being banned in one country but not in another, and of quacks giving medical advice and prescribing drugs over the Internet. The U.S., for instance, made 43 arrests and 22 criminal convictions in 1999 for health-related Internet crimes. In India we do not even have a law to cover telemedicine. The Income Tax Act, 2000, which provides legal recognition to all transactions carried out by means of electronic data exchange and other means of electronic communications, is silent on telemedicine.

If the government, Anna University and others looking at spreading the telemedicine concept want to succeed, they need to study all issues that can overwhelm the technological aspects.