116 A concise text Book of Advanced Nursing Practice

effectiveness of the transfer of information. Definition

Telemedicine is primarily focused on providing support Telemedicine can be defined as, the use of modern
towards curing an illness. Today we have expanded infomation technology, especially two- way interactive
the scope of telemedicine to include the preventive audio/video telecommunications, computers, and
remote patients
and promotive aspects of healthcare. This new avatar telemetry to deliver health services to
is called Telehealth, Tele-Health, E Health or E and to facilitate information exchange between primary
from
Health. care physicians and specialists at some distance
Basics each other. (Telemedicine: Theory and Practice).
Telemedicine is a rapidly developing application of
The term telemedicine' has becn derived from the clinical medicine where medical information is
Greek word tele' meaning 'at a distance' and
'medicine' which is from the Latin word 'mederi' transferred via telephone, the Internet or other
meaning 'healing'. Time magazine called Telemedicine networks for the purpose of consulting, and sometimes
as healing by wire. Though initially considered remote medical procedures or examinations.
futuristic and experimental, Telemedicine is today a Telemedicine is a method, by which patients can be
reality and has come to stay. This phrase was first examined, investigated, monitored and treated, with
coined in the 70s by Thomas Bird. the patient and the doctor located in different places.
InTelemedicine one transfers the expertise, not the
The European Commission's health care telematics
programme defines telemedicine as: "rapid access patient. Hospitals of the future will cure patients from
toshared and remote medical expertise by means all over the world without geographical limitations.
of tele communications and information Telemedicine may be as simple as two health
lechnotogies, no matter where the patient or professionals discussing a case over the telephone,
relevant information is located."A major goal of or as complex as using satellite technology and video
telemedicine is to eliminate unnecessary travelling of conferencing equipment to conduet a real-time
patients and their escorts. Image acquisition, image consultation between medical specialists in two
storage, image display and processing, and image different countries. Telemedicine generally refers to
transfer represent the basis of telemedicine. In plain the use of communications and information

CHDelaivrtehy speak, telemedicine is aprocess bywhich apatient is technologies for the delivery of clinical care.
able to communicate his problems (along with, if Specialties
necesary, details of medical investigations) to a doctor Telemedicine covers a growing number of medical
many miles away and receive necessary and relevant specialties such as:
medical advice. In a lighter vein, when your doctor,
on the phone, told you to 'take an aspirin and call me Cardiology.
Home Care.
in the morning' he was actually practicing
telemedicine. Radiology.
Emergency Care.
The terms e-health and tele health are at times wrongly
Surgery.
interchanged with telemedicine. Like the terms Dermatology.
"medicine" and "healthcare", telemedicine often Psychiatry.
refers only to the provision of clinical services while Oncology.
the term telehealth can refer to clinical and non-clinical
services such as medical education, administration, Pathology.
and research. The term e-health is often, particularly Ophthalmology.
in the UK and Europe, used as an umbrella term that Hematology.
E.N.T.
includes tele health, electronic medical records, and
other components of health IT. Nephrology.
Pre hospital Care.
 Jrate

117
Health Care Delivery
circuit in 1955. In 1971 the
television
Gronth of Tele Medicine Applications to have closed with the Omaha
Nebraska Medical
Center was linked
2001:Tele-radiology -still images. Administration Hospital
and VAfacilities in
Veterans
2002:Tele-cardiology- Moving images. two other towns,
2003: Tele-pathology, Tele-ophthalnology. General Hospital This
station
2004: Tele-oncology, Tele-surgery. 1967: Massachusetts health
005: Mobile Tele Health - augmentation. established in 1967 to provide occupational
was
and to deliver emergency
2006:Telemedicine for Primary healthcare services toairport employees travellers.
medical attention to
VRC care and satcllites.
telemedicine Via ATS-6
1970s: Satellite Alaskan and
History ofTelemedicine paramedics in remote
projects, distant
In these linked with hospitals in
Care at a distance (also called in absentia care), is Canadian villages were
an old practice which was often conducted via post; towns or cities.
ther has been along and succesful history of in absentia time implemented in two areas:
health care, which- thanks to modern communication 1971, Japan: First Kozagawa-cho, Wakayama using
Nakatsu-mura and
echnology- has metamorphosed into what we know Fax transmission and
telephone line for voice and
$ nmoden telemedicine. In its early manifestations,
African villagers used smoke signals to warn people
tostay away from the village in case of serious disease.
CATVsystem for
image transmission.

1972, Japan: Between

Aomori Teishin
over 4 Mhz TV
Hospital and
channel and
2
UNIT
areas in Tokyo Teishin Hospital
Inthe early 1900s, people living in remote dynamo systems came up tor
powered by a several telephone lines. Other like,
Australia used two-way radios, several places in Japan
tele radiology in
driven bya set of bicycle pedals, to communicate with Nagasaki, Tokai etc.
Australia. The
the Royal Flying Doctor Service of
and Applications in Different Forms
idea of performing medical examinations Hospitals and
evaluations through the telecommunication
network Information exchange between
ofthe telephone,
is not new. Shortly after the invention sounds
Physicians. research
attempts were made to transmit heart and lung Networking of group of hospitals,
could assess the state of the
to atrained expert who
HCDealivrtehy
centers.
made hospital.
organs. However, poor
transmission systems Linking rural health clinics to a central
patient and doctor,
the attempts a failure. Video conferencing between a
Einthoven, the father of among members of healthcare teams.
1906: ECG TransSmission
electrocardiography, first
investigated on ECG Training of healthcare professionals in widely
lines in 1906. He wrote distributed or remote clinical settings.
transmission over telephone
cardiograms at the
Archives Instant access to medical knowledge base,
an article Le tele
Internationals Physiologies 4:132,
1906 technical papers etc.
Telemedicine dates back to Types of Telemedicine
1920s: Help for ships
radios were used to link Telemedicine is practiced on the basis of twoconcepts:
the 1920s. During this time,
shore stations to assist
physicians standing watch at Real time (synchronous)
emergencies. 1924:
ships at sea that had medical Perhaps it was the Store-and-forward (asynchronous).
Telecare
Ihe first exposition of from Real time telemedicine could be as simple as a
of"Radio News magazine
COver showed below
April 1924. The article even inchudes a spoof eiecurone telephone call or as complex as robotic surgery. It
the same time
all the gadgets of the requires the presence of both parties at
cicuit diagram which combined them that allows
(Information and photo by and a communications link between
day into this latest marvel Health care IT place. Video
Streveler Ph.D. a real-time interaction to take
COurtesy of Dennis J. common
conferencing equipment is one of the most
Consultant). used in synchronous
Psychiatric forms of technologies
1955: Tele psvchiatn, The Nebraskain the country telemedicine. There are also
peripheral devices which
of the first facilities
nstitute was one
 118
Aconcise text Book of Advanced Nursing Practice

can be attached to computers or the video conferencing Technology Trends in Telemedicine

equipment which can aid in an interactive examination. was introduced more
The concept of telemedicine
of telephone,
For instance, a tele-otoscope allows a remote physician than 30 years ago through the use However,
to 'see' inside a patient's ear; a tele-stethoscope facsimile machine, and slow-scan images.
allows the consulting remote physician to hear the considerably in
the enabling technology has grown
refers
patient's heartbeat. Medical specialties conducive to the past decade. The term telemedicine, in short
this kind of consultation include psychiatry, family tothe utilization of telecommunication technology for
practice, internal medicine, rehabilitation, cardiology, medical diagnosis, treatment and patient care.
pediatrics, obstetrics, gynecology, neurology, and Telemedicine enables a physician or specialist at one
pharmacy. site to deliver health care, diagnose patients, give
Store-and-forward telemedicine involves acquiring intra-operative assistance, provide therapy, or consult
medical data (like medical images, biosignals etc) and with another physician or paramedical personnel at a
then transmitting this data to a doctor or medical remote site. Telemedicine system consists of customized
specialist at aconvenient time for assessment offline. medical software integrated with computer hardware,
It does not require the presence of both parties
at the along with medical diagnostic instruments connected
same time. Dermatology, radiology, and
pathology are to the commercial VSAT (Very Small Aperture Terminal)

UNIT
2 common specialties that are conducive
asynchronous telemedicine. A properly structured
Medical Record preferably in electronic form should
to at each location or fiber optics. Although, telemedicine
could potentially affect all medical specialties, the
be acomponent of this transfer. Telemedicine is most greatest current applications are found in radiology.
beneficial for populations living in isolated communities pathology, cardiology and medical education.
and remote regions and is currently Perhaps the greatest impact of telemedicine may
being applied in be
virtually all medical domains. Specialties in fulfilling its promise to improve the quality, increase
that use
telemedicine often use a tele-" prefix; for example, the efficiency, and expand the access of the healthcare
telemedicine as applied by radiologists delivery system to the rural population and
is called
Teleradiology. Similarly telemedicine as applied developing
countries. Third-generation wireless cellular
cardiologists is termed as tele cardiology, etc. by will offer video telephony that can systems
facilitate
HCaeaDletrhiev ry Telemedicine is also useful as a
between a general practitionercommunication
available at aremote location.
tool
and a specialist
transfer of real-time images to
communications between a patient or ahelp
and a health-care care
the
with
giver
home using known devices Monitoringa patient at professional. Interestingly,
technology offers exactly kind of cost this
monitors and transferring the like blood pressure solutions for the specific the effective
needs arise in rural area
giver is a fast growing emerging information to a care situation.
monitoring solutions have a focus service. These remote
on current Being cost effective, it
morbidíty chronic diseases and are high opens an innovative way
connect rural areas to the to
for the Fast World. In mainly
developing countriesdeployed connectivity to the cities that already have
way of practicing
telemedicine is
a new on LAN. Thus, it Internet or have resources available
known as Primary Remote emerging better and provides a channel enables to bridge
the digital divide
a doctor uses Diagnostic Visits whereby
devices to remotely examine for communication
a patient. This and treat mass. It also makes it to the rural
new technology and of the health possible to get a timely feedback
practicing medicine principle of In situations problems taking
health care delivery holds big promises to solving major of place in remote areas.
epidemic outbreaks such timely
Africa because problems in for instance Southern information can save a significant
Primary As wireless
Consultations not only monitorsRemote
an alreadyDiagnostic technology becomes number of lives.
chronic disease, but has diagnosed affordable, applications such as more ubiquitous and
and managing the diseases the promise to diagnosing POTS willgradualy video telephony over
a general practitioner for. apatient will typicallyvisit migrate towards third
wireless systems. These
mprove the cost and techniques promisegeneration
to greatly
convenience associated with
 accrme o f

.ánce
ements
evemen
Health Care Delivery .ânitig
119

long-term outpatient monitoring, and could potentially Computer based telemedicine systems for military or
extend mnonitoring to the broader healthy population commercial customers can offer Strong safeguards
for preventative diagnostics and alerts. Virtual reality to keep unauthorized eyes and ears from sensitive
as most of us are aware of is the ultimate simulation, information. The core technologies of medical
like entering the rabbit hole in Alice in Wonderland. informatics and networking are in existence today,
Applications in virtualreality for medicine pertain to but major commitment will be required to integrate
the planning of surgeries and use of data fusion, i... them into asystem for the medical battlefield of the
to fuse virtual patientsonto real patients as navigation coming century. First application of telemedicine was
aid in surgery. While research into tele-surgery helps made in disasters during the mid- 1980s. There are
to jump-start robotics in the operating room, distant number of types of disasters such as earthquakes,
nuclear/hazardous chemical accidents, civil disorder/
operations have remained an elusive application.
However, it may eventually prove to be one of the riots, bomb threats/terrorist attacks, bio-wars etc. In
most significant uses of robotic surgery. such situations,the existing terrestrial infrastructure
could be damaged. The space systenms then suitably
Telemedicine in Defence complement partly destroyed terrestrial infrastructure
In early times, following a battle, the opposing forces to answer the requirements of emergency healthcare
services such as fast deployment of the management
retired or the day, leaving the surgeons to go to the
battlefield and attendto the wounded. The focus of
casualty care turned toward first aid with rapid
of logistic and medical means or remote medical
expertise. Appropriate new telemedicine applications
2
UNIT
evacuation to the surgeon and hospital, rather than can improve future disaster medicine outcomes, based
upon immediate advanced medical care to the on lessons learned from a decade of civilian and
individual soldier. Regrettably, many soldiers did not military disaster (widearea) telemedicine deployments.
arrive for treatment within this golden hour for trauma Emergency care providers must begin to plan
surgery. They never lived to receive the benefit
of effectively to utilize disaster specific telemedicine
the sophisticated combat mnedical system in the rear applications to improve future outcomes. As
echelons. Modern technology may make it possible telemedicine technologies and processes gradually
to reduce mortality at the front linesby utilizing that mature, the extent and breadth of medical specialties
golden hour and placing emphasis upon sending the
surgeon back to the front lines in real
tele presence. Medical efforts within the
time but with
defence
telemedicine
where telemedicine technologies could prove clinically
useful should expand. Indeed, reports of telemedicine
implementations are appearing in orthopedics,
HCeDaltirhvey
services show growing acceptance of dermatology, psychiatry, oncology, neurology,
technologies. Surveying the leading edges of pediatrics, internal medicine, ophthalmology and
technology in remote sensing and medical informatics surgery. The price of the underlying technologies for
reveals an opportunity to fundamentally change the telemedicine is dropping. Those trends, combined with
way battle-field casualty care is provided. The keys the increased availability of telecommunications
are remote monitoring of every soldier's location and facilities, indicate that telemedicine will grow more
when you hear
vital signs with Personal Status Monitor (PSM) common. As it becomes more routine
assistance at the casualty side to the medic from a thought of as
the term telemedicine. It won't be
remote physician with Tele monitoring, providing anything special.
immediate surgical care on the battlefield with Tele
therapeutics Medisoft Telemedicine pvt. Ltd. Company
presence surgery, monitoring the route Med soft Telemedicine pvt. Itd. is a
research based
casualties in aTrauma Pod,
and transportation of and
simulation of battle wounds for surgical practice developmnent company.
with virtual
medical forces planning and training particular Objective
delivery by setting the
highest
reality. However, defence services place Toimprove health care publichealth with the help of
security measures Standards in the field
of
emphasis on encryption and other telemedicine ande-health.
for telemedicine.
 Practice
Nursing
Advanced
of
text Book
120 Aconcise
in India
can meet
the
challenges
and. cost
of
Telemedicine

deliveryin an
organized
eficient
exchange of
Goal
of medical practitioners to
the health care
manner
providing
better
access.
information,
To provide accessibility and health care
remotest regions through state
of the art technologies medical expertise
outcomes. AtMed sofl, we Requirement Specification
with optimal cconomical rightto
fimly believe that quality healthcare is the Nodal hospital:
a.
all. getting treated
Telemedicine in India
A patient
A Doctor
Aremote telemedicine console having audio
Existing system limited only to private hospital.
APPOLO Group of Hospitals. visual and data conferencing facilities.
RN Tagore Cardiac Hospital, Calcutta. (Asia b. Referral Hospital:
Heart Foundation). doctor
No Telemedicine system for public health care. Anexpert specialized
Acentral telemedicine server having audio
Corporate Sectors Offering Telemedicine
Systems. visual and data conferencing facility.
APPOLO Group. Sequence of Operation:
Online Telemedicine System, Ahmedabad.
2
UNIT
WIPRO GE.
SIEMENS.
The sequence of operation of the tele medicine
services is simple. The following diagram depicts the
sequence of operation of the tele medicine services.
Telemedicine at Apollo
Apollo Hospitals have been the pioneer in the field of A. On Day 1
telemedicine in India. was the first to set up the
rural telemedicine Centre in the village of Aragonda PATIENT IN
in the state of Andhra Pradesh. It has now
evolved
as the single most largest solution provider for
telemedicine in India. Patient visits Patient receives local
OPD treatment and not

CHDelaivrtehy Telemedicine Services at Apollo Local Doctor referred to telemedicine

check up
Telemedicine reduces the burden of inferior medicine system
access by utilizing technology, reducing time and
for transportation of patients, incorporates cost
clinical, preventive, diagnostic, direct out

services and treatment, consultativeandandtherapeutic Patient referred to the

services, remote monitoring of patients, follow-up systen (some special Telemedicine
may be suggested) investigations
rehabilitation and education for patients. Theservices for
at Apollo is widely appreciated exxpertise
and brings in patients form all throughout the world
clinics. around to the Apollo Patient visits Telemedicine
Console. operator data-entry
Apollo telemedicine facilities entries patient
record, data and images
sitting outside India to consult can help the patients of
results, appointment date is test
and communicate with the doctors at the Apollo for online telemedicine fixed
him
conferences and other through telephone, video
session.
That way, the patients communication technologies.
and information prior are equipped with knowledge
the treatment is to their medical out
tours.
up and post
over and the patients go Even after Ofline Data transfer
from
be done throughtreatment reviews and back, follow Nodal Centre
telemedicine. consultation can
Flow Chart -2.4
 ne

Health Care Delivery 121

B. On Day 2 Data for System Management:

Users 'list
Online conference for Password file
Patient 1
Patient 2 IN the patient. Patient, Logfiles
Patient 3 local doctors at the
Patient 4 nodal hospital and Advantages of Telemedicine
specialist doctors
at the referral hospital Our research has shown that players in healthcare
institutions can gain great benefits from telemedicine.
In particular, telemedicine can provide Comnpetitive
Qut Advantages
Flow Chart -2.5 Better quality: e.g. Faster treatments with lower
level of contamination for the patient;
The Data
Reduction of cost: e.g. Economies of scale and
Data related to a patient's personal informatiòn. scope;
Data related to a patient's medical information.
Data for patient management in Telemedicine,: Information procurement; e.g. University-level
Data related to the doctors. diagnostic competence for small hospital
Data for system management.
Personnel Involved
Standardization: e.g. Organizational and
administrative processes;
Specialization: e.g. Telemedicine-based
2
UNI
Referral end: networks will support professionalization, and
A group of specialist doctors. specialization
System administrator.
Studio technician. IT competence: eg. Increasing number of digital
modalities telemedicine will penetrate the local
Nodal end: routine processes in hospitals and to sustain the
A group of general physicians. IT competence required.
System administrator. Availability of human resources: e.g. Better
Data entry operator. coordination of enlistment periods for radiologists
Studio technician.
Patients.
Patient's Personal Information:
across a teleradiology network;
Shared digital archives: e.g. Digital archives
are an expensive resource and build boundaries
for new entrants;
HCeaDltehrivery
Patient ID
Name Procurement: [Link]-based networks
Age change the bargaining power of healthcare
Sex institutions;
Continued development of treatments: e.g.
Patient's Medical Information: Much better date base of patient records through
Textual. telematics based networks.
Plain Text. Imagine the advantages it confersupon apatient
Structured Document. who is miles away from the nearest medical aid
Image. post, in some cases this could even be lifesaving.
Graphics. For The Patient
Video.
Vector. Telemedicine is cutting edge technology which has
Data Related to the Doctors:
the potential to enlighten YOUR life whatever your
background. As a patient it makes life extremely
Doctors personal information. comfortable and brings super-specialist services
Unique Identification key. almost to your door step, where ever you live.
 Practice
Nursing
Advanced
Book of
122 A concise text Reduced requirement of
costtofmedicare. Apositive
specialists.
of
Availability of selected basic, inter mediate and Reduced
offs. as
Tax write
Superspecialists.

advanced medical facilities within 3to 5kms of a public relations

exercise.
encouraged by
patient's residence. telemedicine schemes
are generally
Reduction in travel to distant referral medical
many states.
centers.
Reduction in cost of medicare.
Administrator or the CEO of a
To aHospital
Better diagnoses of diseases due to availability of hospital
higher efficiency, greater
specialist opinions. Itmeans extended reach, Insurance
Increased and better monitoring of chronic cases. patient satisfaction and higher profits. An
of
Increased domiciliary care. Agency sees it as a means
to cover a larger group
Tele-counselling of selected psychiatric cases. people at lower
costs.
Tele medicine can thus avoid unnecessary travel
and expense for the patient and the family improve Others
India:
outcomes and even save lives. of telemedicine in
Advantages
Once the virtual presence of the specialist is 1. Doctors licensed to practice allover India
acknowledged, a patient can access resources in a 2. Maximum utilization of resources, save time.
tertiary referral centre without the constraints of
2
UNIT ensuring much needed family support.
money and travel.
distance. Telemedicine allows patients to stay at home
3. Make geography, history.
4. International grand rounds, web casting
For The Group conferences.
As a rural group you find the 24 hours advice of 5. Motivation for computer literacy among doctors.
specialists not only agreat support but also arelief as 6. Useful for designing credits for re-certification
it saves many of yourpatients long trips to the nearest of doctor.
city hospital. Better diagnoses of diseases due to Disadvantages:
availability of specialist opinions. Reduction in Kokesh sees only one disadvantage to tele medicine
nosocomial infections due to increased OPD and
perhaps it might best be called too much of a good
domiciliary care. Increased and better monitoring of thing,
DCHelaivrteyh chronic cases. Ability to update oneself. Ability to Itts really hard to match your capacity to do
discuss cases with peers and request advice from telemedicine with what can be an unpredictable
specialists. The general practitioner in the rural/ growth rate, he notes. When we started, we had two
Suburban area often feels that he would lose his dignity. to three cases a week. Now, we have 80
to 90 cases
a week.
With Telemedicine the community doctor continues
to primarily treat the patient to the city consultant. McBeath cites the difficulty of
Patient under a specialist's umbrella. With modern major obstacle to the growth andreimbursement as a
software/hardware at either end 90% of the normal Texas Tech program. development of the
interaction can be accomplished through Telemedicine. Others
For The State
Licensing across state lines.
Better monitoring of disease patterns Lack of standards.
Reduction in diseases due to increasedand trends.
Difficulty in training users and
OPD and
domiciliary care. Early notification of
diseases. Reduced cost of [Link]
equipments maintaining
Reduction in Cost of telecom
urban migration from villages due to better Last mile. infrastructure.
Improved preventive health care medicare.
measures. Do rural homes have
PCs ?
For The Corporate
Hospital/Business Patient confidentiality.
Increased profits from increased virtualMan Telemedicine will soon be just
referrals. Aprofitable franchise. Increased specialist
utilization health care professional, just asanother way to see a
seeing friends and
 Health Care Delivery
family while talking to them on the phone is becoming 123
commonplace. Technology manufacturers and video. Ten years or fifteen years
telecommunications companies are already flying with we would rely heavily
and e-mail, tools on faxes,
ago we had no
idea
each other to produce the low cost
equipment and for granted. which are now answering machines
bandwidth needed. Distance education Since low-tech and
place and most educational is common Health (a general early 2000, the taken
institutions, and many term ramifications of B
companies allay travel costs for
meetings by using delivery, administration
and its relationship
encompassing
andinformation health care
to dissemination)
telemedicine are being
UNIT END EXAM analysed.
Long Essavs QUESTIONS