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    Telemedicine a boon in remote Patient Care

    TELEMEDICINE: A BOON FOR MEDICAL TOURISM

    AN INDIAN PERSPECTIVE

    INTRODUCTION

    Medical Tourism is a process where people travel across borders for treatments including medical, surgical dental or cosmetic needs, due to higher treatment costs in their countries, delays in the getting the treatment and sometimes even legal reasons.

    During this medical tour, they also get the pleasure of exploring and experiencing the various tourist destination in that country. Thus, the concept of medical tourism is based on combining prompt medical treatment with travel and tourism at a fraction of cost incurred in the patient’s own country.

    As per today’s trend, countries like India, Singapore, Thailand, Jordan, Malaysia, Philippines, Brazil, Turkey, Costa Rica etc are very well liked amongst the medical tourism fraternity. Above all, India has drawn a great deal of attention of numerous medical tourists by offering economical, speedy and world class health care facilities with superior technology and competent healthcare personnel; Introduction of Ayurveda and Yoga to foreign nationals while promoting exotic tourist places has made India the most sought-after location. The Medical industry is in full boom in India as more than 5.9 million overseas tourists are expected to visit India in 2010 while the figure is anticipated to go beyond 6.3 Million in 2011. The average annual growth rate in the number of international medical tourists’ arrival to the country is predicted to be 7.46% during 2009-10 which is much higher than previous figure of 5.85%. As of now, a number of medical tourism facilitators successfully operate in India by providing ‘Delight’ to their international clients.

    However, interaction between healthcare provider and receiver is the subject of prime concern in the medical tourism industry of India. How can a patient conform to a doctor? How can a doctor be sure of the kind of treatment he would advice without personally examining a patient?

    That is where the telemedicine comes to help. It plays a pivotal role by bridging the communication gap between care receiver and provider. In today’s era, telemedicine has revolutionized the medical tourism industry in India by making physical distances irrelevant and by abolishing the absolute necessity of long distance traveling.



    TELEMEDICINE – AN OVERVIEW

    Telemedicine is generally defined as delivery of clinical health care by using telecommunications as well as information technologies, irrespective of physical location. Telemedicine = ‘Tελε’ (Tele – a Greek word meaning ‘distance’) + ‘mederi’ (a Latin word meaning ‘to heal’) and therefore it literally means “Distance Healing”. During medieval time, villagers of Africa used to send smoke signals as a warning to people to remain away from the village in case of some serious disease. In the beginning of the previous millennium, two-way radios, powered by a dynamo, driven by a set of bicycle pedals, were used by Australian villagers as a communication link with the Royal Flying Doctor Service of Australia. With the passage of time, it is becoming a fast progressing and extremely advantageous medical application where quick exchange of medical data is made possible by telephone, internet, video conferencing equipment and satellite technologies for the purpose of real time consultation, examination and remote medical procedures. Telemedicine is now becoming very useful in a many spheres of medicine like Radiology, Pathology, Cardiology, Dermatology and Psychiatry.

    Telemedicine can be used in two forms: Real Time (Synchronous) and Store & Forward (Asynchronous).

    Real Time Telemedicine can be practiced only when both care provider and receiver are present at their respective places at the same time. It requires audiovisual devices which make real time interaction possible. There are many peripheral aids such as Tele-Bronchoscope, Tele-Stethoscope, Tele-Otoscope, Tele-Retinoscope, Tele-Pathology Microscope and Tele-Scanner which can also be used to further enhance the real time evaluation of the distant patient.

    Store & Forward Telemedicine is the process of transmitting medical information and records in form of Images, X-Rays, Lab Reports, CT Scans, Blood Slide Microphotographs, MRI, Angiograms, Voice or Text Dictation on the patient's history etc, to a remote physician at any time which would be assessed and evaluated at doctor’s own time. The simultaneous presence of both parties is not mandatory in this kind of telemedicine.

    TELEMEDICINE – TECHNICAL ASPECTS

    Basic technical requirements for effective transmission of patient data are as follows.

    • Telephone connections with international calling facilities.
    • Integrated Service Digital Network (ISDN) - minimum 128 kbps.
    • Very Small Aperture Terminal (VSAT) - Bandwidth of 384 kbps.
    • High Speed Broadband Internet - 512 kbps Bandwidth.
    • Video Conferencing System – with 256 ISDN or IP based support.
    • 1 KV UPS (uninterrupted power supply) with air conditioned support.
    • 29” flat television.
    • Minimum 15x12 feet size comfortable air conditioned room with a couch.

    TELEMEDICINE – AN INDIAN SCENARIO

    In India, telemedicine facilities are primarily utilized to provide health care services to rural communities where primary medical services are inadequate and also to educate health workers functioning in remote localities. With the use of newer technologies, significant proportion of rural patients could be successfully managed locally with competent guidance from specialists practicing in cities, without having to travel to the specialists. In India, telemedicine programs are actively supported and promoted by Government of India (Department of Information Technology, Ministry of Communications and IT), ISRO, NEC (Telemedicine program for North-Eastern states), Apollo Hospitals, Asia Heart Foundation, IIT Kharagpur, CDAC Pune, CEDTI Mohali, various State Governments and other private organizations.

    In recent times, many innovations are being carried out in India in the field of telemedicine. For instance, Narayana Hrudayalaya Institute of Cardiac Science, Bangalore (conceptualized and founded by Dr. Devi Prasad Shetty, a renowned Cardiac Surgeon) has been developing telemedicine software which can transmit ECG using Trans Telephonic ECG Machine. Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) Lucknow have been working on development of indigenous softwares (Mercury & Sanjeevani) for telemedicine and its applications in collaboration with Centre for Development of Advanced Computing (CDAC) Pune and Center for Electronics Design and Technology of India (CEDTI), Mohali. Because of intricacies of its sophisticated equipments, it is truly difficult to ascertain the precise cost of telemedicine technology. It may vary depending upon specifications/configurations of its components, location as well as its network expansion and supplier of various paraphernalia. Equipment for real time interactions and for store and forward exchanges are also not similar and differ in their cost.

    Facility of telemedicine is available at many corporate hospitals in India. Most prominent are Apollo Hospitals, Wockhardt Hospitals, B.M. Birla Heart Research Centre, Escorts Heart Institute & Research Centre, Max Health Care, Asian Heart Institute, Fortis Health Care and Columbia Asia Hospitals. Apollo Hospitals have been leading the way in the field of telemedicine in India. It brings in a lot of medical tourists from all over the world. Apollo telemedicine facilities help foreign patients to consult the doctors at various Apollo hospitals and communicate with them through telephone, video conferences and other communication technologies.

    TELEMEDICINE - LEGAL OUTLINE

    There was no Indian law/regulation existing on the issues raised by the use of Information technology for practice and provision of healthcare until 2003. With the increasing usage of informational technology, it became quite necessary to understand and address the challenging issues in the field of Indian medical tourism especially licensure, supervisory authority, penalties, liability, confidentiality/privacy, medical negligence and so on. The Telemedicine Act, 2003* was enacted subsequently which regulates the provision of healthcare services by the use of telecommunications technology and for any matters connected therewith. In spite of this act, the issue on insurance coverage for expenditure incurred on telemedicine treatment remains disputable.

    TELEMEDICINE – AN EFFECTUAL TOOL

    · Pre-Procedural:

    As a routine practice, SurgeryPlanet suggests various countries/hospitals/doctors to the patient according to his/her medical condition and budgetary criteria. Out of which, patient decides on a particular country/hospital/doctor. Subsequently, SurgeryPlanet will send relevant details of the patient along with previous medical records and other necessary documents electronically for thorough review by remote care provider. At times, patient himself can interact with distant care provider through telecommunication or video-conferencing equipment which may enable the remote physician to assess and evaluate the actual medical condition of the patient. Before actual traveling, this sort of initial encounter and rapport between care receiver and care provider may prove to be an ice breaker and plays an imperative role in entire process. It also helps building confidence and friendliness between two of them. Consequently, patient starts confiding in the doctor as the process goes on further. Appointment, pre-medication, traveling counseling can also be obtained electronically before commencing the journey.

    Sometimes patient may not able to describe his/her own medical condition because of complexity of the clinical symptoms or language diversity. These issues can tactfully be handled by using the services of a healthcare professional practicing locally. In such case, telemedicine proves to be an essential link between a local doctor and a remote physician.

    · Monitoring and Follow up:

    Post treatment monitoring and follow up is as crucial as treatment itself. Any lapse during the convalescence phase may adversely affect the outcome of the entire therapeutic process. Patient is invariably kept hospitalized for few days after treatment/surgery and afterwards he/she usually spends few days/weeks on local sightseeing and tour. But variety of medical and surgical disorders, for instance most cardiovascular diseases and gastrointestinal surgeries, require prolong monitoring of the patient, may be for weeks or months. Local care provider in patient’s own country can utilize various modes of telemedicine for sending regular reports of the patient’s progress to the remote physician. For any emergency situation, interaction between remote physician and local care provider can only be made possible by telemedicine. Periodic follow up of patients can remotely be done by real time monitoring of Blood Pressure, Heart Rate and Rhythm, exercise induced ECG changes, SPO2 etc with the help of telemedicine.

    TELEMEDICINE: A HARBINGER OF TROUBLE? NO NO.

    However there are many hurdles are experienced on the way to effective medical tourism. Potential dangers and pitfalls of telemedicine can very well be surmounted with the appropriate usage of technologies. Huge installation cost of telemedicine technology, expensive routine maintenance as well as imparting technical training to its handlers is the primary concern while establishing a new facility. But emergent acceptance of technologies, innovative trends and cut throat competition in the field of medicine would surely tackle the issue of cost. It is also noted that rapid technological changes might lead to duplicity, incompatibility or even obsolescence of different hi-tech telemedicine equipment.

    Any form of distant communication, audiovisual or otherwise, inevitably results into variable proportion of information loss in transmission. In addition to that, many patients fail to correctly comprehend the instructions or medical reports/records may not be interpreted in the approved manner by remote care provider due to language disparity or faulty technological systems. This is a very serious issue having an adverse impact on almost all facets of medical outcome which can be minimized by using technically high quality information exchange systems according to different situations. Expert assistance of a professional interpreter can also be sought.

    Issue of confidentiality and secrecy of patient’s information, personal as well as medical, is raising another red flag. That is why many patients do not prefer to disclose their identity or they are hesitant to provide much information during initial interactions across the networks. In many cases, they feel insecure about information networks and start believing that they are being eavesdropped and intercepted by hackers and spammers. They also doubt to what extent the confidentiality of the relationship between the patient and the doctor will be maintained. Security of information regarding a person’s physical condition, psychological condition and treatment is an essential requisite for telemedicine applications. To prevent such chaos, security strategies need to be redesigned. Highest protection of all computers and communication network systems should be ensured. Telemedicine systems must only be accessible to authorized handlers. Obligatory legal rules and standards should be enacted and enforced at all costs. A set of morals and ethics are needed to be incorporated into the medical tourism companies and remote care providers.

    Difference in time zones of geographically distant countries is another significant trouble faced by many medical tourists. This leads to encounters happening at odd night hours. Prior appointment at suitable time for both parties can make things easier. Store & Forward (Asynchronous) type of telemedicine may be considered where possible.

    When the remote physician asks the local doctor to perform certain physical examinations like checking for fluid thrill on abdomen or auscultating breath sounds, there may always be difference of opinion because such findings are purely subjective in nature. Perception and interpretation about such examination vary from individual to individual. Moreover, there are some medical procedures that can’t work as well using real time telemedicine, particularly in neurology. It is very difficult to accurately analyze the finest movements of tremor and reflex over video.

    Telemedicine Act, 2003 does not offer any explicit standards for telemedicine technology and softwares in particular. Telemedicine software used in India should be compatible worldwide, so that telemedicine could be used in promoting medical tourism. The legal framework should also include regulations to ensure confidentiality and network security in transmission of personal information. Telemedicine requires collaborative effort between various ministries such as health, science, communication and IT as well as autonomous bodies such as Insurance Regulatory Development Authority (IRDA). Because telemedicine is considered as a form of cross-border trade under the General Agreement on Trade in Services (GATS), appropriate regulations are required to be evolved for making telemedicine and medical tourism easy between various countries. International organization like the World Health Organization (WHO) is also engaged in developing standards for telemedicine.

    CONCLUSION

    It may reasonably be assumed that telemedicine is an integral component of medical tourism industry. Telemedicine is a medium-of-choice for exchange of the information not only before treatment cycle but also for remote monitoring and follow-up after the treatment is over. In view of the fact that the medical tourist is always a distant individual, the physical gap cannot be easily bridged without effective use of telemedicine. Further, patient’s local care provider may often not be capable to give enough medical assistance in many clinical situations and needs to be instructed regarding what all to be done and what not. This can currently be accomplished only through telemedicine. With the help of SurgeryPlanet’s wide network of hospitals and Doctors, Tele-medicine can easily be under taken.