OMD553 –TELEHEALTH TECHNOLOGY

UNIT 1
TELEMEDICINE AND HEALTH

SYLLABUS : History and Evolution of telemedicine, Organs of telemedicine, Global and

Indian scenario, Ethical and legal aspects of Telemedicine - Confidentiality, Social and legal
issues, Safety and regulatory issues, Advances in Telemedicine.
TELEHEALTH

Telehealth defined:
“The delivery of health-related services and information via telecommunications technologies”
•Could be: (nonclinical services)
•Two healthcare professionals discussing a case over the phone
•Using videoconferencing between providers at facilities in two countries

Telehealth can promote:

•Patient-provider communication
•Patient self-management with provider feedback
•Health literacy Search for diagnosis and educate patients
•Provider-provider consultants

Telemedicine
Definition : Telemedicine
• Telemedicine is the remote delivery of healthcare services, such as health assessments or
consultations, over the telecommunications infrastructure. It allows healthcare providers
to evaluate, diagnose and treat patients using common technology, such
as videoconferencing and smartphones, without the need for an in-person visit.
• These technologies allow communications between patient and medical staff with both
convenience as well as the transmission of medical, imaging and health informatics data
from one site to another.
• It is also used to save lives in critical care and emergency situations.

• Combination of:
•Telecommunications Technology
•Medicine (clinical services)
 Telemedicine is the future of global healthcare.

Benefits to Healthcare Professionals

 Improved and diagnosis better treatment management
 Continuing education and training
 Quick and timely follow-up of discharged patients
 Access to computerized comprehensive data of
 patients, both offline & real time

Benefits to patients
Access to specialized health care services to under-served rural, semi-urban and remote areas
• Early diagnosis and treatment
• Access to expertise of Medical Specialists
• Reduced physician‘s fees and cost of medicine
• Reduced visits to specialty hospitals
• Reduced travel expenses
• Early detection of disease
• Reduced burden of morbidity

Where the telemedicine used ?

 • Follow-up visits: Virtual follow-ups and check-ups can be used in place of in-person
visits and even help prevent hospital readmissions. The likelihood of missed
appointments and no-shows also decreases with telemedicine — it‘s far easier to log onto
a secure video call than to take time off from work for an in-person appointment.

• Chronic disease management: Telemedicine software and mobile health (mHealth)

software play vital roles in the effective management of chronic diseases. Chronic
diseases already take a toll on patients; telemedicine is an easy and affordable way for
patients to actively maintain control over their health and their relationship with their
caregiver.

• Assisted living visits: Telemedicine offsets the need for in-person visits to assisted
living facilities. Doctors and caregivers can remotely visit their patients at any time of
day, and ultimately reduce unnecessary visits to the hospital.

Classification OR Categories of Telemedicine

Remote patient monitoring (RPM), also referred to as telemonitoring, allows providers to

track and monitor their patients with chronic diseases (diabetes, hypertension, etc.). RPM
solutions equip remote caregivers with vital patient data such as blood sugar or blood pressure
levels so that they can review such data in nearly real time and get notified if a measurement is
abnormal. RPM solutions makes it possible for chronically ill, at-risk or recovery patients to
stay at home instead of being confined to a hospital or clinic.
Examples of RPM :
• Glucose trackers
• Wearable devices that track health and fitness levels
• Smart beds that monitors patients‘ health, communicate with hospital devices and
equipment and automatically make necessary adjustments
• Sensors that monitor the gait and balance of patients with walkers and canes

Store-and-forward/asynchronous applications
• Asynchronous telemedicine solutions, commonly referred to as store-and-forward
telemedicine, enable providers to easily store and share patient medical data with other
providers and practices.
Examples of store-and-forward applications:
• Teleradiology solutions that send patient X-rays to another radiologist
• Teledermatology solutions that send patient photos for remote diagnosis
• Telepsychiatry solutions that enable remote behavioral health treatment

Real-time telehealth applications

• Synchronous telemedicine exists as well. It is also known as real-time telehealth and it
facilitates real-time communication between physician and patient. Generally, real-time
telehealth solutions take the form of audio and video communication and replace in-
person visits.
Examples of real-time telemedicine:
• Live video and audio conferencing
• Emergency virtual consultations
• Remote follow-up visits
 Examples for Telehealth vs. Telemedicine

Why Telemedicine/Telehealth?
•Access: Time, Travel, Expense, Information -------- No need for travel.
•Health Provider Collaboration. ------------ prevent patients from becoming advanced cases and
acquiring more cost.
•Enhanced Communications
•TV & Computer Applications common and non- threatening
•Minimize referrals
Communication/Collaboration with specialists
•ER ‗front-line‘ support. →Small hospital will alert a big hospital if it couldn't handle a patient .
so, it consults for or transports this patient.
•Improved professional education
•Saves time, travel to outreach clinics

Challenges of Telehealth
• Infrastructure
• Liability
• Privacy Privacy psychiatry patient will be hesitate of using it.
• End-user lack of knowledge about the benefits, services available in other settings
• Compromised relationship between health professional and patient
• Lack of time to adopt telemedicine
• Equipment costs
• Connectivity costs ,Reimbursement
• A lack of appropriate ,training and educational facilities
• The legal and ethical issues including licencing, privacy and confidentiality
•
History of Telemedicine
Various forms of telecommunication and information technologies have evolved with time. On
these bases, we can identify four phases of the development of tele-health corresponding to the
use of these technologies (Table-1).

Table – 1: Phases of Tele-health Development

Development phase Approximate time frame
Telegraphy and telephony 1840s-1920s
Radio 1920 onwards till 1950s
Television/space technologies 1950s onwards till 1980s
Digital technologies 1990s onwards

 Clinical or healthcare information over telephone, or broadcasting it over radio stations..

 Marconi‘s invention of the radio-telegraph in 1897, which was used during the American
CivilWar to send casualty lists and order supplies.

 1906:ECGTransmission
Einthoven, the father of electrocardiography, first investigated on ECG transmission over
telephone lines in 1906.

 1920s: Help for ships

Telemedicine dates back to the 1920s. During this time, radios were used to link
physicians standing watch at shore stations to assist ships at sea that had medical
emergencies.

 1924: The first exposition of Telecare --- TELEDACTYL

Perhaps it was the cover showed below of "Radio News" magazine from April 1924. The
article even includes a spoof electronic circuit diagram which combined all the gadgets of
the day into this latest marvel! . Hugo Gernsback, predicted that physicians would use not
the telephone, but radio and TV to communicate with patients.

 1955 Telepsychiatry : Closed-circuit television service begun in 1955; used in hospitals

The Nebraska Psychiatric Institute developed a two-way link with Norfolk State Hospital,
112 miles away, in 1964 with further extensions in 1971. This project is one of the first of
many examples of tele-psychiatry.

 1967: Massachusetts General Hospital

This station was established in 1967 to provide occupational health services to airport
employees and to deliver emergency care and medical attention to travelers.
 The National Aeronautics and Space Administration‘s (NASA) efforts in tele-health
began in the early 1960s when humans began flying in space. Physiological parameters
were telemetered from both the spacecraft and the space suits during missions.

 1970s: Satellite telemedicine

Via ATS-6 satellites. In these projects, paramedics in remote Alaskan and Canadian
villages were linked with hospitals in distant towns or cities.

 Project STARPAHC - Space Technology Applied to Rural Papago Advanced Health-

Care. STARPAHC aimed at providing medical care to astronauts in space and to the
Papago Indian Reservation in Arizona. This service was carried out through a van that
was equipped with a variety of medical instruments, including electrocardiograph and x-
ray. The van was linked to the Public Health Service hospital and another hospital with
specialists, by a two-way microwave tele-health and audio transmission.
  In the later parts of 1970s, Alaska Satellite Biomedical Demonstration Program and
various other Canadian projects were begun, to serve far-flung areas.

 The first truly international tele-health program, known as Space Bridge, was
implemented by NASA. It was done to provide relief to people after a terrible earthquake
jolted Armenia in 1988 and cased severe devastation.

 The North-West Tele-health Project set up in Queensland, Australia, was the only major
tele-health project outside North America until 1990. This project was designed to serve
rural communities. The project-goals were to provide healthcare to people in five remote
towns, south of the Gulf of Carpentaria.

 This development was followed by Meaningful Use regulation and the Affordable Care
Act in 2010 where Accountable Care Organizations (ACOs) were created to push for the
maturation of telehealth capabilities.

 It‘s a fairly obvious statement to say that 2016 was the year of telehealth. Even though
the push for its inception started in late 2014 and showed signs of becoming a real
movement in 2015.

 In 2016, $16 million was given by the federal government to improve access to
healthcare in rural areas. Some of the money was designated for the use of the technology
for veterans and others. While we‘re not where many thought we might be, especially
more than 120 years ago, most physicians think the effort is a top priority and will lead to
improved patient outcomes and access to care.

 In 2017, the concept will be unrestricted, paid for and covered, and continue expanding to
a wider audience. For the arguments of telehealth being used to serve the disenfranchised
and the rural poor, telemedicine is set for widespread use.

 There is an expansion of the technology through the use of internet-connected everything

devices and as virtual medical facilities take shape, but there‘s been excitement about the
concept before now. Telehealth is likely a real concept now, but even with new
developments, that doesn‘t mean all of this can‘t be derailed.

The Evolution of Telehealth

One of the landmark publications of the past couple of decades, Crossing the Quality Chasm,
stated, ―information technology must play a central role in the redesign of the health care system
if a substantial improvement in quality is to be achieved‖. Nowhere is this more true than in rural
communities. New knowledge and new science are being developed all the time. When some
people have access to that new knowledge and expertise and other people do not, disparities
grow. Advances in telecommunication and information technology can help overcome some of
these disparities by redistributing that knowledge and expertise to when and where it is needed.

HOME- AND COMMUNITY-BASED CARE

Health care in the home-based setting has a long history. For example, an 1879 article in the
Lancet talked about using the telephone to reduce unnecessary office visits. In 1925, a cover of
Science and Invention magazine showed a doctor diagnosing a patient by radio, and within
envisioned a device that would allow for the video examination of a patient over distance. Home
monitoring developed more fully in the Mercury space program when the National Aeronautics
and Space Administration (NASA) began performing physiologic monitoring over a distance.
NASA further developed this technology with a pilot with the Papago Indians, the Space
Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project.

The biggest need in home- and community-based care relates to chronic disease. The 100 million
Americans with chronic disease account for about 75 percent of health care expenditures.
Traditionally, chronic disease has been managed through an episodic office-based model rather
than a care management model, which uses frequent patient contact and regular physiologic
measurement. Use of technologies for chronic disease care management has been associated with
reductions in hospitalizations, readmissions, lengths of stay, and costs; improvement in some
physiologic measures; high rates of satisfaction; and better adherence to medication. Studies of
home monitoring programs have shown specific improvements in the management of
hypertension, congestive heart failure, and diabetes.

OFFICE-BASED TELEMEDICINE
Telemedicine has also been used for decades in clinical settings. In 1906, the inventor of the
electrocardiogram published a paper on the telecardiogram. Since the 1920s, the radio has been
used to give medical advice to clinics on ships. Alaska has been a model for the development and
use of telemedicine for decades. For example, community health aides in small villages can
perform otoscopy and audiometry, and the information can be sent to specialists in Anchorage or
Fairbanks to make the determination of whether a patient needs to travel to the specialist for
more definitive treatment. Today, we think of office-based telemedicine as flat-screen, high-
definition units with peripheral devices that can aid in physical examination of the patient. There
are a lot of these units out there, all of which do not talk to each other, and some of which use
proprietary communications methods. If telemedicine is to become as ubiquitous as the
telephone, communications standards will be needed.

Store and forward (S&F), or asynchronous, technologies have been a great advance. For
example, in ophthalmology and optometry, non-mydriatic cameras can be used to perform retinal
screenings in diabetics without needing to dilate the eyes; this has increased screening rates.
Teledentistry has been used to by dental hygienists and dentists to improve access to oral health
care. Dermatology and psychology are two of the biggest areas for telemedicine. Since the
1990s, studies have shown high rates of agreement between diagnoses made in person and
diagnoses made via teledermatology.

ANCILLARY TELEMEDICINE SERVICES

Teleradiology
Teleradiology has been used for at least 60 years. In the past, film was passed through a digitizer;
now most systems use direct digital capture, which allows images to be read overnight in other
countries. Radiologists have promoted the Digital Imaging and Communications in Medicine
(DICOM) standard for transmitting and storing data. By the late 1990s, studies showed that
teleradiology reduced transports for head injuries out of rural areas and that the availability of
teleconsultation with a radiologist significantly affected diagnosis and treatment plans.

Telepathology
Telepathology is less common than teleradiology, but digitization of pathology slides is
becoming much more common. These are very large files, which require the ability to view color
images under different magnifications. A lot of people were concerned about moving these large
files across firewalls, but now a number of models being developed have the image sitting on a
server and the image can be viewed over distance without needing to be moved. Studies have
shown the value of telepathology.

Telepharmacology
Pharmacy has been practiced over distance for a long time. Telepharmacy is facilitated by
computerized physician order entry, remote review, and even remote dispensing. Combining that
with video, being able to review medications, and conducting a video consultation with a patient
allows the whole pharmacy visit to occur over distance. In one recent study on 47 cancer
patients, 27,000 miles of travel were saved because of telepharmacy.

HOSPITAL-BASED TELEMEDICINE
Probably one of the earliest and most famous uses of hospital-based telemedicine was in the late
1950s and early 1960s when a closed-circuit television link was established between the
Nebraska Psychiatric Institute and Norfolk State Hospital for psychiatric consultations. Hospital-
based telemedicine is growing quickly in two areas: stroke care and care in the intensive care
unit (ICU). Evidence shows that with good imaging, high-quality stroke exams can be done over
distance. Although the literature on tele-ICU has been mixed, recent studies indicate associated
reductions in length of stay, mortality, and costs.

A number of devices are being used in inpatient setting as well as in skilled nursing facilities.
Telemedicine reduces avoidable visits to emergency departments for skilled nursing patients.
Some rural skilled nursing facilities exist in communities that do not have physicians, and getting
physicians there urgently can be a challenge.

Organs of telemedicine
Types of Telemedicine
Telemedicine is the use of medical information shared from one site to another using electronic
communications to improve patient‘s clinical health status.
The American Telemedicine Association (ATA) also includes a growing variety of applications
and services using two-way video, email, smartphones, wireless tools, and other forms of
telecommunications technology under the telemedicine umbrella. Patient consultations via video
conferencing, transmission of still images, e-health (including patient portals), remote
monitoring of vital signs, continuing medical education, consumer-focused wireless applications,
and nursing call centers, among other applications, are all considered part of telemedicine and
telehealth.
The Center for Connected Health Policy (CCHP) says, ―Telehealth is not a specific service, but a
collection of means to enhance care and education delivery.‖
According to the CCHP, there are four categories for telehealth use today.
These are:

1. Live video-conferencing Telemedicine Or Real-time telemedicine

Also known as synchronous video, live video-conferencing is a live, two-way interaction
between a person and a healthcare provider using audiovisual telecommunications technology.
This kind of telehealth is often used to treat common illnesses, to determine if a patient should
proceed to an emergency room, or to provide psychotherapy sessions.

Synchronous telemedicine exists as well. It is also known as real-time telehealth and it

facilitates real-time communication between physician and patient. Generally, real-time
telehealth solutions take the form of audio and video communication and replace in-person
visits.
Examples of real-time telemedicine:
• Live video and audio conferencing
• Emergency virtual consultations
• Remote follow-up visits

2. Store-and-forward or asynchronous Telemedicine

Store-and-forward is involves acquiring medical data (like medical images, biosignals etc.) and
then transmitting this data to a doctor or medical specialist at a convenient time for assessment
offline. It does not require the presence of both parties at the same time. Dermatology (cf:
teledermatology), radiology, and pathology are common specialties that are conducive to
asynchronous telemedicine. A properly structured medical record preferably in electronic form
should be a component of this transfer. A key difference between traditional in-person patient
meetings and telemedicine encounters is the omission of an actual physical examination and
history. The ‗store-and-forward‘ process requires the clinician to rely on history report and
audio/video information in lieu of a physical examination.

Asynchronous telemedicine solutions, commonly referred to as store-and-forward telemedicine,

enable providers to easily store and share patient medical data with other providers and practices.

Examples of store-and-forward applications:

• Teleradiology solutions that send patient X-rays to another radiologist
• Teledermatology solutions that send patient photos for remote diagnosis
• Telepsychiatry solutions that enable remote behavioral health treatment

3. Remote patient monitoring (RPM)

RPM is the collection of personal health and medical data from a patient or resident in one
location that is then transferred electronically to a nurse, caregiver, or physician in a different
location for monitoring purposes. RPM is already being used to a great extent in senior living in
order to prevent falls and monitor the vital health statistics of residents.
Examples of RPM :
• Glucose trackers
• Wearable devices that track health and fitness levels
 • Smart beds that monitors patients‘ health, communicate with hospital devices and
equipment and automatically make necessary adjustments
• Sensors that monitor the gait and balance of patients with walkers and canes

4. Mobile health or mHealth Telemedicine

mHealth uses mobile communications devices, such as smartphones and tablet computers, and
hundreds of software applications for these devices, which can do almost anything imagined for
supporting healthcare. Examples of healthcare apps and how valuable they are for senior care
will be discussed later in this eBook.

Indian Scenario
Initiatives
In a developing country such as India, there is huge inequality in health-care distribution.
Although nearly 75% of Indians live in rural villages, more than 75% of Indian doctors are based
in cities. Most of the 620 million rural Indians lack access to basic healthcare facilities and the
Indian government spends just 0.9% of the country's annual gross domestic product on health,
and little of this spending reaches remote rural areas. The poor infrastructure of rural health-
centers makes it impossible to retain doctors in villages, who feel that they become
professionally isolated and outdated if stationed in remote areas.

In addition, poor Indian villagers spend most of their out-of-pocket health- expenses on travel to
the specialty hospitals in the city and for staying in the city along with their escorts. A recent
study conducted by the Indian Institute of Public Opinion found that 89% of rural Indian patients
have to travel about 8 km to access basic medical treatment, and the rest have to travel even
farther. Telemedicine may turn out to be the cheapest, as well as the fastest, way to bridge the
rural–urban health divide. Taking into account India's huge strides in the field of information and
communication technology, telemedicine could help to bring specialized healthcare to the
remotest corners of the country.

The efficacy of telemedicine has already been shown through the network established by the
Indian Space Research Organization (ISRO), which has connected 22 super specialty hospitals
with 78 rural and remote hospitals across the country, through its geo-stationary satellites. This
network has enabled thousands of patients in remote places, such as Jammu and Kashmir,
Andaman and Nicobar Islands, the Lakshadweep Islands, and tribal areas of the central and
northeastern regions of India, to gain access to consultations with experts in super-specialty
medical institutions.

ISRO has also provided connectivity for mobile telemedicine units in villages, particularly in the
areas of community health and ophthalmology. Other then that, both public and private entities
are aggressively pursuing the use of telemedicine to hasten diagnostics and treatment of a variety
of diseases in India.

 Private hospitals such as Apollo Hospital Group.

 Escorts Heart Institute and Fortis Healthcare.
 The Apollo Hospital Group has networked dozens of remote rural hospitals providing
digital connections to one of its main facilities in. In one example, Apollo has set up a 50-
bed telemedicine center in Aragnoda, a small village in the Andhra Pradesh section of
south India. The facility is equipped with CT-scans, X-ray and ECG equipment as well as
an integrated laboratory and is linked to Apollo's specialized hospitals with connectivity
is conducted through the use of ISDN lines and VSAT. The Indian government has also
made important commitments to telemedicine by reducing import tariffs on infrastructure
equipment
 Department of Information Technology (DIT)
  Indian Space Research Organization
 NEC Telemedicine program for North-Eastern states
 Asia Heart Foundation
 Stategovernments

Hindrances to Telemedicine
 Financial unavailability: There have been several isolated initiatives from various
organizations and hospitals for the implementation of e-medicine projects in India; but
the technology and communication costs, being too high, make it financially unfeasible
 Lack of basic amenities: In India, nearly 40% of the population lives below the poverty
level. Basic amenities like transportation, electricity, telecommunication, safe drinking-
water, primary health-services, etc., are missing. Any technological advancement can‘t
change a bit when a person ―has nothing‖ to change.
 Literacy rate and diversity in languages: Only 65.38 % of India‘s population is literate,
with only 2% well-versed in English. So the rest of the people are facing a problem in
adopting telemedicine. Also, the presence of a large number of regional languages makes
the applicability of a single software difficult for the entire country.

Advantages of Telemedicine in India

 Doctors licensed to practice all over India
 Maximum utilization of limited resources
 Saves travel, time and money
 Make geographical history
 Motivation for computer literacy among doctors
 Useful in designing credits for re-certification of doctors
A time is approaching when telemedicine/e-health initially shall be visibly
practiced in the majority of Indian hospitals, as a separate department, before eventually fusing
into the respective medical specialties.

Global scenario
Telemedicine can also be concisely referred to as ―the use of information and telecommunication
technologies (ICT) in medicine‖ . Telemedicine is just not only for remote monitoring or
diagnosing a patient (comparative performance of seven long-running telemedicine networks
delivering humanitarian services .It also includes e-learning techniques (to remotely deliver
education both to health care workers and to patients), and teleconsultation (aka telecounseling
or expert second opinion) services. This latter refers to any consultation between doctors or
between doctors and patients on a network or video link (e.g., Facetime, intranet, Internet,
Skype, etc.), as opposed to the ―in person‖ counseling where no ICT is needed to manage the
interaction between the patient and the physician(s).

In developed countries several programs have been deployed, and they have been promptly
reported for 10–15 years , where the program has been mainly used for remote education (76%
of the considered cases), without neglecting other goals such as wound cases (55%), and
psychiatry cases (54%), and store-and-forward ECG (ElectroCardioGraphy) recordings.

To provide the reader with an economic evaluation of the effort, the telemedicine market in
Europe increased from an amount of €4.7 billion in 2007 to the amount of €11.2 billion in 2012 –
the European Commission (EU) estimates . Additional world-wide estimations assert that the
global telehome and telemedicine market reached an amount of US$ 13.8 billion 2012, US$ 16.3
billion 2013, US$ 19.2 billion 2014, and this market is expected to grow up to US$ 35.1 billion
in 2018, US$ 43.4 billion in 2019, with a compound annual growth (CAGR) of 17.7%. Some
more estimations evaluate that the European telemedicine market grew from US$ 3.1 billion in
2010 to US$ 4.8 billion in 2011, and will almost triple to US$ 12.6 billion in 2019 at a CAGR of
12.82%; at the worldwide level, the market of telemedicine reached an amount of US$ 14.4
billion in 2015, and is expected to grow up to US$ 34.0 billion in 2020, with CAGR of 18.6%.

Much less effort has been spent for similar initiatives in developing countries. Probably, this is
due both to the much smaller return of investment (ROI), to a limited budget available, and to the
greater difficulties expected or encountered also due to the lack of technological infrastructures.
Moreover, while telemedicine programs in developed countries in most cases may easily deploy
an emergency strategy, such as sending out an helicopter to rescue the patient and to transfer
him/her to the nearest hospital in a very short time, similar situations in developing countries are
generally more expensive and much harder to be deployed. Finally, in developed countries,
telemedicine is side-by-side to more conventional health care, completing it, while in developing
countries telemedicine in most cases is an alternative, or even the only alternative, to
conventional health care. Nevertheless, telemedicine applications in developing countries could
be a leverage to provide wide populations with basic health care services and to close the
distance between rural areas and specialized hospitals usually located in big cities.

Efficacy and the cost-effectiveness of telemedicine compared with conventional health care still
are to be properly evaluated in fact, major aspects to be considered include the amount of saved
lives (e.g., some people would have died without the aid of a telemedicine system), and the
quality of life of saved people (e.g., some people would have been completely restored if the
telemedicine system could suggest them a first-aid assistance). As for the cost-effectiveness, to
the best of our knowledge, are the only ones to measure the economic benefits achieved by a
telemedicine program: they just sum up the travel costs to move a specialist physician from a
main hospital to the remote hospital, or to move the patients from the remote hospitals to the
main hospital.

According to the previous considerations, telemedicine applications in developing countries need

to be studied, designed, and evaluated according to specific criteria, which have to take into
account cultural, environmental, organizational, and economic peculiarities of the considered
countries and populations.
Telemedicine services
To obtain an impression of the current state of telemedicine service provision, four of the most
popular and established areas of telemedicine were surveyed specifically. Respondents were
asked to indicate whether or not their country offered a service in each field, and if so, to give its
level of development. Levels of development were classified as ‗established‘ (continuous service
supported through funds from government or other sources), ‗pilot‘ (testing and evaluation of
the service in a given situation), or ‗informal‘ (services not part of an organized programme).

The survey examined four fields of telemedicine:

TELEMEDICINE RESULTS
 Teleradiology – use of ICT to transmit digital radiological images (e.g. X-ray images)
from one location to another for the purpose of interpretation and/or consultation.
 Telepathology – use of ICT to transmit digitized pathological results (e.g. microscopic
images of cells) for the purpose of interpretation and/or consultation.
 Teledermatology – use of ICT to transmit medical information concerning skin
conditions (e.g. tumours of the skin) for the purpose of interpretation and/or consultation.
 Telepsychiatry – use of ICT for psychiatric evaluations and/or consultation via video
And telephony.

Advances in Telemedicine
Recent Advances
 The first randomised controlled trial of home telenursing showed evidence of its cost
effectiveness
  Electronic referrals are a cheaper and more efficient way to handle outpatients
 General practitioner teleconsulting may be cheaper than traditional consulting in some
circumstances
 Decision support over video links for nurse practitioners dealing with minor injuries is
shown to be effective and safe
 Call centres and online health meet a demand from the public, but are unlikely to be
cheaper for the NHS.

Recent technological advancements have changed the way we see the world, paving the way for
the growth of concepts such as telemedicine in the field of medical technology. Telemedicine is a
method of providing clinical healthcare to someone from a distance by the use of
telecommunication and information technology.

Previously, telemedicine was reserved for treating patients located in remote areas, far away
from healthcare facilities, or in locations with a shortage of medical professionals. However, in
today‘s interconnected world, I believe telemedicine is now a tool for convenient medical care—
its use is no longer limited to overcoming distance barriers or improving access to medical care.
Today‘s connected patient wants to waste less time in the waiting room at the doctor‘s surgery
and get immediate care for minor but urgent conditions when they need it.

Importance of TeleMedicine

Benefits for Patients:

1. No travel expenses and no time spent waiting around for appointments
2. Less interference with childcare or eldercare responsibilities
3. Reduced medical costs provide value to the patient
4. Extended access to consultations with specialist doctors
Benefits for Providers:
1. Increased revenue
2. Fewer missed appointments and cancellations
3. The ability to treat more patients over time
4. Better patient follow-up and improved health outcomes

Trends in Telemedicine

1. Patient Data Collection and Data Analytics: During a telemedicine session, patient
information is automatically captured by the use of telemedicine services, such as sensors
and mobile apps. Using this data and the slew of modern devices available, patient self-
monitoring has been huge in 2017 and will continue to grow in 2018 and beyond. Some
devices track patient ECG‘s and send the results to doctors, providing an invaluable tool
for healthcare professionals to monitor cardiovascular activity. Also, Big Data analytics
plays a key role in analyzing data from many patients, helping to improve telemedicine
treatments as a whole going forward. Patient data collection can help identify risk factors
for certain illnesses, assisting physicians with recommending prophylactic treatments.

2. Mobility and Cloud Access: By 2018, it‘s estimated that 65 percent of interactions with
healthcare facilities will occur with mobile devices. 80 percent of doctors already use
smartphones and medical apps in their practice. Hospitals and insurance companies now
store medical records in the cloud so that patients can access their test results online 24/7.
This, in turn, decreases paper usage and saves time. Cloud data warehouses are one way
of storing the data securely and efficiently.
 3. Enhanced Security: With lots of data being collected from patients to assist with
telemedicine services, data security is vital. There are different techniques available today
which help to enhance data security in telemedicine, including:
 Conducting a HIPAA security check once a year to reduce data security risk
factors
 Insisting on encryption of data on all portable devices
 Conducting more frequent penetration testing and vulnerability assessments of IT
systems

4. Better Investment Opportunities: Because telemedicine is one of the fastest growing

segments in the healthcare industry, many organizations are investing in it. Mergers
between small and larger telemedicine operators provide financial stability to smaller
companies and a platform to provide telemedicine care effectively. Also, larger
telemedicine providers are collaborating with international medical institutions, helping
them to spread their expertise abroad, widening the telemedicine market, and generating
more revenue. Investment opportunities in telemedicine will only increase as India and
China open their doors to telemedicine practices from the west.

5. Better Healthcare Apps: In the coming years, we can expect more personalized
telemedicine apps for both patients and clinicians, with the flexibility to specify the
information transmitted between doctor and patient. Telemedicine app development also
will give rise to mHealth, also known as mobile Health. Apps such as MDLIVE, Amwell,
MyTeleMed, and Express Care Virtual will facilitate convenient interactions between
patient and physician.

Telemedicine services provide cost-effective treatments and less wasted time for patients and
physicians. Increased prevalence of chronic diseases, technological advancements -- particularly
in software -- and a rise in the aging population are major factors driving the massive growth in
telemedicine. Expect to see telemedicine become much more prominent in healthcare over the
coming years, with more patients than ever having access to top-quality medical care at their
fingertips

TELE-HEALTH: ISSUES&CHALLENGES

Confidentiality and Privacy

Tele-health represents a new approach to health-care, with the potential for improving
accessibility and reducing costs. Over the years, technology has become increasingly interactive,
cheaper and standardized. Despite this, the uptake of technology has been low. One of the main
reasons is that the introduction of telemedicines in health-care requires more than technology and
software organizational and cultural change is required as well. A suggested approach is based
on the principals of service quality and quality management, to produce a partnership between
the users and developers of new technologies. This will, in turn, make it possible to bring user-
validated requirements into the design of the system and create feelings of ownership and
motivation on the part of users, in order to prepare their environment for the change. The
methodology has been effectively used in various projects of the Telemedicine Application
Program of the European Commission.

Ethical and Legal Aspects:

Patients, Physicians and the Internet:
The implications of the Internet have permeated this text, suggesting that it will be a major
influence on the way we practice medicine and the way in which patients assume increasing
responsibility for their own care. As testimony to its impact, a recent poll has shown that more
than 98 million US adults have sought healthcare information online and 75% of those who have
access to the Internet use it to find health-related information. This explosive growth brings
threats as well as opportunities, and many clinicians are unprepared, both technically and
mentally, for the new patient power and the ethical and legal dilemmas that the new paradigm
produces.

For example, physicians now find that they need to provide online services, such as web sites,
direct email communication, and question-and-answer sessions, to help interpret the information
that patients acquire. They are also concerned about the amount of time they need to spend with
patients to explain the shear mass of data and the way in which the Internet is reducing the
asymmetry of the patient-doctor relationship. Governments must be aware of and respond to
these pressures by educating the public and providing a legal framework in which unethical and
irresponsible practice can be exposed and the offenders punished. This framework should
involve healthcare professionals and industry, and should encourage them to construct ethical
codes and act in a self-regulatory manner in order to minimise malpractice and maximise patient
benefits.

Ethical Guidelines for Patient-Information:

Informed users quite naturally expect clinical information on the Internet to be of high quality,
i.e. accurate, timely and based on evidence. That is, they expect the content of a web-site to be
governed by the same principles as scientific and professional publications. Thus, they want to
know the names and affiliations of the authors, their declared interests and the date of publication
of the web information, as well as the names of any sponsors. Naive users have less critical
faculty and are more easily persuaded of the validity of what they read on a web-page. However,
all users require information to be presented in ways that facilitate its retrieval, so that they can
draw the maximum benefit from it. They also need the assurance that any information they
themselves provide will remain private and confidential Several organizations have endeavoured
to enshrine these principles in guidelines or codes of ethical practice for the construction of
Internet websites.

The Hi-Ethics consortium is a voluntary group, which aims to: unite the most widely used
consumer health-Internet sites and information providers whose goal is to earn the consumer‘s
trust and confidence in Internet health services.

The objectives of Hi-Ethics are to:

- Offer Internet services that reflect high quality and ethical standards;
- Provide health-information that is trustworthy and up to date;
- Keep personal information private and secure, and employ special precautions for any
personal health information
- Empower consumers to distinguish online health-services that follow these principles from
those that do not.

Ethics and Legality of Internet Based Medical Services:

To date, the use of the Internet to deliver medical services has been largely restricted to advice in
a patient-carer setting or to the dispensing of prescriptions. In the former situation, the value of
the online therapy to the patient is clearly dependent on the credentials and expertise of the carer.
Even if the qualifications and status of the clinician are above question, (and these may be
difficult to assess) it does not follow that this person can exploit the new medium to offer the
care that he or she would provide in a traditional consultation. There are also many opportunities
for misunderstanding, due to the absence of visual clues and the tendency for the mind to fill in
knowledge gaps in an idealistic way.
 Other Issues and Challenges

Improving User-Acceptance of Health-Care Telemedicines:

Tele-health represents a new approach to health-care, with the potential for improving
accessibility and reducing costs. Over the years, technology has become increasingly interactive,
cheaper and standardized. Despite this, the uptake of technology has been low. One of the main
reasons is that the introduction of telemedicine in health-care requires more than technology and
software----organizational and cultural change is required, as well. A suggested approach is
based on the principals of service-quality and high-quality management, to produce a partnership
between the users and developers of new technologies. This will, in turn, make it possible to
bring user-validated requirements into the design of the system and create feelings of ownership
and motivation on the part of users, in order to prepare their environment for the change. This
methodology has been effectively used in various projects of the telemedicine Application
Program of the European Commission.

Managing the 'Fit' of Information and Communications Technology in Community-

Healthcare.
The 'fit' of information and communication technologies (ICT) in community health is important
in meeting the needs of patients, carers, staff and organizations in the delivery of services. A
good fit leads to greater efficiencies and effectiveness in use of ICT. There is a need to look not
only at the role of ICT, but also at how to manage ICT and make a good ICT fit so as to enhance
community health-services. Tele-health was identified as the application of ICT to enhance
population-health, health promotion and delivery of health-service. A participatory process is
critical to determining needs and potential uses, as well as to the successful design and
implementation of ICT in health. There would be an additional value in ensuring a diversity of
desired outcomes, which can balance costs and benefits while fostering capacity and technical
sustainability.

Preparing Doctors & Surgeons for the 21st Century - Implications of Advanced Technologies
An entire spectrum of advanced technologies and concepts has been presented, from the new
clinical applications to highly speculative possibilities. Not all of these technologies will survive
the long process to clinical usefulness, but those that do may well revolutionize surgery and other
medical procedures. With such change comes the ethical and moral responsibility to consider
them not only in the light of improvement of patient care, but also in their impact on society as a
whole. Fundamental changes in the organization, financing, and delivery of health-care have
added new stress-factors or opportunities to the medical profession. These new potential stress-
factors are in addition to previously recognized external and internal ones. The rapid deployment
of new information-technologies will also change the role of the physician towards being more
of an advisor and provider of information. Many of the minor health-problems will increasingly
be managed by patients themselves and by non-physician professionals and practitioners of
complementary medicine.

Library Outreach:
Addressing the "Digital Divide": A "Digital Divide" in information and technological literacy
exists today between small hospitals and clinics, in rural areas, and the larger health-care
institutions in the major urban areas of the world. Some efforts have been made to address
solutions to this disparity; one of them is the outreach-program of the Spencer S. Eccles Health-
Sciences Library at the University of Utah, in partnership with the National Network of Libraries
of Medicine-- Midcontinental Region, the Utah Department of Health, and the Utah Area Health-
Education Centers. In a circuit-rider approach, an outreach librarian offers classes and
demonstrations throughout the state that teach skills of information-access to health-
professionals. Provision of traditional library-services to unaffiliated health-professionals is
integrated into the library's daily workload, as a component of the outreach program.
Managing Changes in Informatics-The Organizational Perspective:
The successful introduction of information-systems into any healthcare organization whether a
primary care physician's office, or a complex health care organization-requires an effective blend
of good technical and good organizational skills. A system that is technically excellent may
prove woefully inadequate if people resist its implementation. The person who knows how to
manage the organizational impacts and stresses of new information-systems can significantly
reduce behavioral resistance to change and resistance to new technology in particular to achieve
a more rapid and productive introduction of those systems.

Patient e-Care – Addressing the Concerns of the Providers

Online patient-care or patient "e-care" could revolutionize the centuries-old paradigm of medical
practice. Patient e-care can bring back the "house call" experience, long missed by consumers,
and could potentially allow healthcare to become proactive rather than reactive. Moreover,
patient-monitoring and interactive management data can be fed directly into patient‘s electronic
medical records. Consumers/patients embrace the concept of e-care. Providers, however, tend to
be threatened by a change of the medical practice paradigm and by the (perceived) impingement
upon providers' hectic time-schedules. Most providers felt that they did not have enough time in
their busy schedules (i) to learn the new technology required, (ii) review daily patient-data, or
(iii) interact with their patients online.

Providers expressed a need for solutions that offer better patient-care but would also not require
more time from the providers. Technical e-care solutions must address both patient-wants and
provider-concerns. Solutions that save time for providers, while still offering the advantages of
patient ecare, must be found. For example, Internet software that automatically monitors and
even manages some aspects of a patient's condition, while keeping the provider informed,
appears to be one solution.

e-Content: the Challenge of Providing Authentic & Quality Health- Information:

Health information is amongst the most frequently accessed informations on the web.
Accordingly, the breadth of health-information offered on the web is vast. However, a new
public-health concern is the extremely variable quality of health-related information on the
Internet, ranging all the way from reliable, evidence-based information, to fraudulent,
commercially motivated, unbalanced or misleading information. For patients and consumers, and
even for health-professionals, it is often difficult to judge the trustworthiness of digital
information.