1. Telemedicine : A low cost solution Anunay Nayak Jayanta Mukherjee Arun Kumar Majumdar Department of Computer Science and & Engineering IIT Kharagpur

2. A brief sketch of our journey May 1997 : Invitation for a proposal by MCIT (then DOE) on Telemedicine over ordinary telephone lines. March 1998 : Submission of a Draft proposal in collaboration with School of Tropical Medicine and WECS (WEBEL).Draft proposal Jan 1999 : Starting of Project Work. Aug 2000 : A Prototype system developed (TelemediK Software Version 1.0) Nov 2000 : Installed in STM for in house training and demonstration. Feb 2001 : First beta test between STM Kolkata and IIT Kharagpur. Feb 2002 : Inauguration of Telemedicine between School of Tropical Medicine, Kolkata and Habra State General Hospital. April 2002 : Inauguration of the second nodal center at Cooch Bihar. May 2002 : Project involving connections of six hospitals of Government of West Bengal is taken by WEBEL (IIT Kharagpur being the consultant).Project involving six hospitals Nov 2002 : TelemediK version 3.0 with a better front end and flexibilities in users operations.

3. Nodal Hospital Referral Centre Writers Bldg. State Switching Centre DM OFFICE District Switch Centre 2 Mbps Optical Link WBSWAN 512 Kbps Leased Line Schematic Diagram for Proposed Telemedicine using WBSWAN

4. Field trials and demonstrations –Between West Bank Hospital, Mourigram and B.C.Roy Hospital, IIT Kharagpur –Between IIT Extn. Center Bhubaneswar and IIT Kharagpur –CMC Vellore. –Chittaranjan Cancer Research Center, Kolkata. –National Institute of Cholera and Enteric Diseases, Kolkata. –ELITEX’ 2001 and ELITEX’ 2002, New Delhi. -Sikkim Manipal Institute of Medical Sciences, Sikkim -Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha

5. What is Telemedicine Telemedicine may be defined as the use of computers and telecommunication technologies to provide medical information and services from distant locations

6. Different types of services  Telecardiology  Teleradiology  Telepathology  Telepsychiatry  Early Warning System [ Prevention and control of endemic and infectious diseases ]

7. Telemedicine in India Existing system limited only to private hospital APPOLO Group of Hospitals. RN Tagore Cardiac Hospital, Calcutta. (Asia Heart Foundation) No Telemedicine system for public health care Corporate Sectors Offering Telemedicine Systems APPOLO Group Online Telemedicine System, Ahmedabad. WIPRO GE SIEMENS

8. Government Efforts MCIT IIT Kharagpur CDAC ISRO

9. Why it is relevant to our society Poor infrastructure Non-availability of experts ( disparate distribution ) Low doctor-patient ratio ( large population ) Lack of proper medical education Special attention required for Public Health Care System

10. Major Challenges Poor Data Communication Infrastructure. A Large Population Catered by Government Hospitals. System Features should be scalable. Cost of the system should be scalable.

11. Aim of the Telemedik System Information management –Patient information –Medical data (signs, symptoms, test reports, etc..) –Appointment scheduling –Archival and retrieval of patient records Low cost solution –Using ordinary telephone line Service to large population –Through public health care delivery systems Development of knowledge-based system –For decision support –For training and education

12. Key Principles Avoid Adhocism : Preorganisation of Patient Data Minimize online data transfer Patient Management with Database support

13. Technical issues over Low Bandwidth ProblemSolution Longer time for data transfer Poor video quality Store and forward policy Transferring sequence of still images

14. Requirement Specification Nodal Hospital Referral Hospital A patient getting treated A Doctor A remote telemedicine console having audio visual and data conferencing facilities An expert/ specialized doctor A central telemedicine server having audio visual and data conferencing facility POTS / ISDN

15. Sequence of Operation PATIENT IN Patient visits OPD Local Doctor checks up Patient receives local treatment and not referred to telemedicine system Patient referred to the Telemedicine system (some special investigations may be suggested) Patient visits Telemedicine data-entry console. Operator entries patient record, data and images of test results, appointment date is fixed for online telemedicine session OUT Offline Data transfer from Nodal Centre Day One

16. Sequence of Operation Patient 1 Patient 2 Patient 3 Patient 4. Online conference for the patient. Patient, local doctors at the nodal hospital and specialist doctors at the referral hospital Patient queue IN OUT Day Two

17. Hardware Configuration Digital camera Referral Hospital Nodal Hospital PSTN/ISDN/VSAT link Scanner Printer Modem Microscope and other medical instruments Video Conference Telephone

18. Software Modules Offline Activities Online Activities

19. Offline Module Data Acquisition Data Distributor Temp Files Local DB Data Encryption Data Sender Data Receiver Data Distributor Patient data Browser User Interface Data Decryption Master Database Temp Files D A T A Acknowledgement NODAL CENTREREFERRAL CENTRE Data Flow Diagram For Off line Communication

20. Online Module Data Acquisition Online Session Coordinator and communicator Online Session Coordinator and communicator Local DB Online Session Coordinator and communicator Online Session Coordinator and communicator Master DB Secure Communication Channel NODAL CENTREREFERRAL CENTRE Data Flow Diagram For Online Communication Video Conferencing

21. The Data The Data Data related to a patient’s personal information Data related to a patients medical information Data for patient management in Telemedicine Data related to the doctors Data for system management

22. Employment Generation Extension of existing services. Personals involved.

23. Personnel Involved Referral end A group of specialist doctors System Administrator Studio technician Nodal end A group of general physicians System administrator Data entry operator Studio technician Patients

24. Other Issues Incorporation of Standard. Health Level Seven (HL7) Digital Imaging Communication in Medicine (DICOM) Data Security. Legal & Ethical Issue

25. Patient’s personal information Patient ID Name Age Sex ……

26. Patient’s medical information  Textual  Plain Text Plain Text  Structured Document Structured Document  Image Image  Graphics Graphics  Video Video  Vector Vector

27. Plain Text

28. Structured Document

29. Images

30. Vector Data

31. Graphics

32. Video Clip

33. Data for patient management in Telemedicine

34. Data related to the doctors Doctor’s personal information Unique Identification key

35. Data for system management  Users’ list  Password file  Log files

36. Digital Imaging Communications in Medicine ( DICOM ) originally the ACR-NEMA  developed by American College of Radiology (ACR) and the National Electrical Manufacturer's Association (NEMA) provides standardised formats for image capture and storage coupled with a common information model specifying service definitions and protocols for communication

37. HEALTH LEVEL SEVEN HL7: Health Level Seven standards for the exchange, management and integration of data  that support clinical patient care, and the management and delivery of healthcare services defines the protocol for exchanging clinical data between diverse healthcare information systems  Australia, Canada, Finland, Germany, India, The Netherlands, New Zealand, South Africa and the United Kingdom

38. Teleradiology over WBSWAN

39. Telemedicine for Tropical Diseases