For the 620 million Indians living in rural areas, the greatest medical advance to come their way since the polio vaccine may be, well, the computer. Srikanth R P examines the potential of Telemedicine in India

January 26, 2001 was a significant day for India in more ways than one. Apart from being the country’s Republic Day, the day was also marked by the devastating earthquake in Gujarat. Some 40,000 lives were lost, and over one lakh people were badly injured. The need at that point in time was to immediately treat the injured and provide healthcare facilities to prevent further deaths. But given the magnitude of the calamity, the number of available medical personnel proved inadequate. To make matters worse, many hospitals and other medical facilities were destroyed by the earthquake.

Sanjay P Sood feels that telemedicine guidelines will encourage the application of the system and infuse confidence into users and beneficiaries

In this gloomy scenario one promising technology made its impact: Telemedicine. The day after the earthquake, the Ahmedabad-based Online Telemedicine Research Institute (OTRI) came to the rescue and established the first communication link from Bhuj, which was close to the epicentre of the quake. Within the next four days, OTRI established a disaster management system with online transmission from places like Rapar, Bhachau, Gandhidham, Anjar and Ahmedabad, with the control room based at Gandhinagar. Specialists were able to provide consultations from far-off places, thanks to the established telemedicine links. For example, after the telemedicine centre was set up at Bhuj hospital, an X-ray facility was provided to the people whereby a specialist provided online consultation from Ahmedabad. During the subsequent days, quake victims could get medical advice from other doctors based at Ahmedabad and Bangalore. Over 750 sessions were established in a period of 30 days, thus saving many lives.

What is telemedicine?
Telemedicine is a method by which patients can be examined, monitored and treated, while the patient and doctor are located in different places. The patient’s reports can be sent via text, voice, images or even video, and medical advice offered from a remote location.

To know why telemedicine is important in the Indian context, consider the following statistics. Though over 620 million people live in rural India, medical specialists are mostly confined to urban areas. There is only one hospital bed available for 1,333 Indians, and one doctor per 15,500 people. Only 9 percent of our one billion people are covered under health schemes. Add to this the difficulty posed by India’s vast geographical spread, and it is obvious why healthcare providers are looking to telemedicine to reduce India’s healthcare problems.

Importance
Rural patients have to travel huge distances, and thus incur considerable expenses, everytime they need to consult a doctor. In some of these cases the same treatment could have been carried out by a local doctor with advice from a specialist living elsewhere. Further, as in any profession, medical specialists tend to focus more on large metros rather than sparsely populated towns—which works to the detriment of the non-urban populace.

Dr K Ganapathy, medical director of Apollo Telemedicine, explains its importance in the Indian context: “In Utopia every citizen has immediate access to the appropriate specialist for medical consultation. But in the real world this cannot even be a dream. It is a fact of life that while ‘all men are equal, some are more equal than others.’ We are at present unable to provide even total primary medical care in rural areas. Secondary and tertiary medical care are not uniformly available even in our suburban and urban areas. Incentives to encourage specialists to practice in suburban areas have failed. In contrast to the bleak scenario in healthcare, computer literacy is fast developing in urban and suburban areas. Prices of computer equipment and accessories are crashing. Thus, theoretically, it is far easier to set up an excellent telecommunication infrastructure in suburban and rural India than to place hundreds of medical specialists in these places.”

One of the biggest benefits telemedicine provides is the death of distance. Deploying it can reduce unnecessary travel, expense and even strain. Once the virtual presence of a specialist is acknowledged, a patient can access medical resources without the constraints of distance. It also solves the problem of retaining specialists in non-urban areas. For instance, since Chennai has three medical universities, there are more neurologists and neurosurgeons in the city than in all the states of the North-East put together. But the increasing availability of telecommunication infrastructure and video conferencing equipment can make a doctor virtual and give his valuable knowledge to anyone, anywhere in the country.

Says Sanjay P Sood, member, interim council, International Society for Telemedicine, “Health and education are key areas of concern in India. To improve the reach, quality, speed and efficiency of healthcare delivery systems, particularly in a country like India, telemedicine is extremely effective.”

Sood gives the example of Himachal Pradesh (HP): “A state with predominantly hilly terrain, HP has over 91 percent of its population in villages. Barely 44 percent of the villages are linked with all-weather roads. 18 percent of the villagers have to travel at least 10 kilometres to reach a hospital. The population will cross nine million by 2020 (currently over six million.) The infant mortality rate is 60 per 1,000 births, which the government intends to reduce to 15 by 2020. But with HP’s current infrastructure and facilities, it seems unrealistic to expect that the 2020 health targets will be met—unless telemedicine is adopted in a big way.”

Apart from Gujarat, there are a couple of other cases that show the potential of the technology. For example, during the last Kumbh Mela which drew over 25 million pilgrims to the banks of the Ganga for the holy dip, telemedicine was deployed successfully. OTRI, together with a team of tech-savvy doctors, transferred data of over 200 ailing pilgrims, besides sending microscopic images of micro-organisms in order to monitor the levels of cholera-causing bacteria in the river. Another example is the Asia Heart Foundation that has been successfully practising telecardiology between Bangalore and cities in eastern India.

But the biggest success story is Apollo Hospitals, which is also one of the pioneers of telemedicine in the country. It began with a pilot project—a secondary level hospital that it established in Aragonda village in Andhra Pradesh (AP). This 40-bed hospital was equipped with a CT scan, a modern ultrasound, and an incubator. Starting with simple Web cameras and ISDN telephone lines, the village today has a state-of-the-art video conferencing system, and a VSAT installed by ISRO. The success of the project can be seen from the fact that around 200 teleconsultations have been provided to this village by specialists in Chennai. There are no fixed hours for teleconsultation; a medical officer is available at the telemedicine unit in Chennai from 9 am to 5 pm. Additionally, arrangements are being made to provide emergency teleconsultations. Detailed clinical examinations can be made possible. In almost all cases, the teleconsultant was able to give a definite opinion and guide the local physician. Today, Apollo is providing expert opinion from its tertiary level hospitals in bigger cities to those in far-flung areas of India. In 27 months, over 4,000 patients have benefited through teleconsultations with Apollo’s doctors—and over 75 percent of them were treated in their respective home towns.

Telemedicine for competitive advantage
Telemedicine is also an effective marketing tool; it enables hospitals to address the needs of patients who might not otherwise have used their services. In addition, telemedicine can be used as a medium to impart training.

Explains Dr Saji Salam, consultant, healthcare and life sciences practice, Cognizant Technology Solutions, “Telemedicine is an effective medium to impart knowledge to professionals within a healthcare organisation. This becomes relevant in corporate hospital chains spread across the country; now they can share and institutionalise best practices across the group. Telemedicine can also be used to provide public health education to the remote corners of India.”

In a country like India where healthcare insurance is yet to catch up, and the cost of care is usually borne by patients, telemedicine can go a long way in reducing their burden, says Dr. Saji Salam

How does the system work?
A basic telemedicine system consists of a personal computer, a modem, a telephone line, a scanner and a webcam. Telemedicine covers a wide range of activities. In the past it was primarily tele-radiology, transferring high resolution X-rays, ultrasound, CT scans, MRIs and ECGs. Today, the same system can enable a doctor to conduct a detailed clinical examination remotely. What’s more, gloves with special sensors are available, which give tactile feedback from a transmitted image.

While a very basic telemedicine system can do with a PC, telephone and scanner, it needs to be scaled up as needs increase. Sachin Rawat, manager, operations, doctoranywhere.com, sums it up appropriately: “Telemedicine comes in various varieties, so permit me to use the analogy of the Rolls-Royce and Maruti 800. Clearly, India’s demographic structure and income disparity demand the Maruti 800 model, which is scalable, affordable and easily maintainable. A store-and-forward basic product with a normal Pentium PC, a webcam, telemedicine tools (to capture patient data or images) and an Internet dial-up connection would provide the same results as a fancy real-time application. But for communication between any tertiary-to-tertiary care hospital, we would need a Rolls-Royce type of infrastructure: video conferencing equipment with software, a minimum of 256 Kbps leased line connectivity, X-ray scanner, digital camera, flatbed print scanner, digital ECG recorder, ultrasound machine with digital output, digital microscope, and two Pentium 4 PCs. The money needed to deploy this kind of solution is around Rs 30-40 lakh per site, with a recurring cost of Rs 3-4 lakh per annum.”

By contrast, a store-and-forward system (‘Maruti 800’) is extremely cost-effective. A central server can store all the information about cases to be referred to the concerned specialist. The expenditure to deploy this kind of solution is around Rs 2-3 lakh per site, which is ten times less than the ‘Rolls-Royce’ model. Moreover, the cost of the central server can be shared by all the sites in the network.

From the simple traditional model, telemedicine technologies have evolved over the years to handle complex tasks. Explains Dr Ganap-athy, “Electronic stethoscopes can transmit sounds from the lungs and heart, from one continent to another, without any alteration in the quality of the sound. Traditionally, only the physician at the other end of the stethoscope could hear the sound, and interpretation was dependent on what was between the two ear-pieces. Today, the same sounds can be heard through a speaker phone by an unlimited number of doctors in faraway places. The sounds can be compared with those in different diseases from a referral sound laboratory, and the specific problem can then be identified. A wide variety of internal and external examinations can be done with a patient far away. Endoscopic cameras peering into the patient’s interior can be manipulated from several thousand miles away. Dermascopes can transmit skin injuries in the natural colour since they offer a choice of several million colours. Detailed diagnosis and monitoring of patients can be done remotely by using sophisticated medical probes and monitors. Access to multimedia patient records, medical databases and treatment algorithms is just a click away.”

Impact on rural India
Says Dr Salam, “Think of a patient in Tinsukia, Assam, who requires consultation with a specialist in Mumbai. For him, access to the care he needs is a challenge since expenses like travel, accommodation and food add substantially to the total cost of treatment. In a country like ours where healthcare insurance is yet to catch up, and the cost of care is usually borne by patients, telemedicine can go a long way in reducing their burden.”

There’s another powerful argument in favour of telemedicine. Studies have shown that in the case of rural patients, risk of death is twice that of urban patients with similar injuries. Explains Sood, “Factors like discovery time, transport time and inexperienced providers all add up to aggravation in the nature of the disease, which can lead to death. Telemedicine can help patients increase awareness about their state of health, and hence reduce the discovery time. Also, a patient need not be transported to a city since telemedicine is based on a different principle: move the clinical information rather than the patient. Hence telemedicine, if practised ethically, promises to bring the rural population on par with the urban population as far as healthcare services are concerned.”

While the potential of telemedicine is great, its impact has not really been felt in rural India. One reason is the awareness of the obvious risks involved in recovering investments. The need of the hour therefore is to keep patients only at lower hospitals when the disease is not that serious and the patient can be managed at that level. A case in point is a pilot project being carried out at IIT Kharagpur. The ministry of IT supports this project, which covers the Institute of Tropical Disease at Howrah, and caters to two hospitals in remote areas.

Further, healthcare providers need to understand that though the technology is effective, there has to be continuous effort by both the government and the private sector to ensure the benefits of telemedicine reach the common man. Opines Dr Ganapathy, “Telemedicine, being a revolutionary idea, requires close support from different arms of the government. To succeed in rural areas, it has to be on a not-for-profit basis. Close co-operation between public enterprises and private enterprises is essential—the former generating funds, and the latter implementing the project.”

Current scenario
One can see a small but encouraging movement across the Indian landscape. Apollo, which started with Aragonda, is expanding to cover other lesser-connected towns and villages of India. Narayana Hrudayalaya of Bangalore is another success story in telemedicine; it mainly caters to North-East India.

Dr Saroj Mishra believes that ISRO’s decision to launch an exclusive satellite to service healthcare will provide a major boost to the growth of the telemedicine industry in India

Key challenges
As in any industry, inadequate infrastructure hampers the growth of telemedicine. For instance, connectivity for telemedicine is not possible when many of the remote villages do not have connectivity in the first place. There’s also a shortage of computer-savvy healthcare professionals, almost no exposure to usage of computer applications in the curriculum of medical colleges, and a lack of training facilities with regard to application of information and communication technologies in medicine.

Then there’s the question of standards; there is confusion whether the various telemedicine systems set up in India will be able to talk to each other. Hence there’s a need for certain technical standards to be agreed upon and implemented. Declares Dr Salam, “A few years down the line when corporate mergers and acquisitions become commonplace in the healthcare sector, integration to leverage investments may face a major roadblock.

Integrating disparate systems could be expensive unless standards are followed from day one.”

While telemedicine in India is still in its embryonic stage, the government has taken a series of steps to make sure that it turns out to be one of the biggest success stories. For instance, recently, the department of information technology framed guidelines for telemedicine in India. These guidelines also take care of legal issues that can arise from using this technology.

The framing of the guidelines has given a boost to an industry, which is seen by many as the only practical solution to India’s healthcare problems. Says Sood, “India’s healthcare industry is worth over $16 billion, and is expected to grow by 13-15 percent annually. The telemedicine guidelines will encourage the application of the system, and infuse confidence in users and beneficiaries.” Additionally, the launch of an exclusive satellite by ISRO to service healthcare needs is revolutionary—the satellite can address the issues of connectivity for remote villages in India.

Adds Dr Saroj Mishra (who has been involved in telemedicine R&D since 1999), “ISRO’s announcement will provide a major boost to the growth of the telemedicine industry in India. If connectivity access is provided it can create a national health information highway that will provide state governments with access to high bandwidth communications.”

While a lot of positive steps have been taken, there are still a lot of things to be done if India wants to fulfil its dream of providing healthcare to all its citizens. Explains Dr Ganapathy, “A national high-power task force on telemedicine should be formed with committed representatives from various organisations. A short-, medium- and long-term plan should be drawn up at the level of the district, state, region and country. To ensure that this task force implements what is recommended, it should be autonomous and have access to funds. The force should comprise doctors, IT specialists, telecommunication experts, health economists and health administrators.”

Besides having the potential to solve some of India’s healthcare problems, telemedicine can be a big opportunity for India’s software industry as well. As Dr Mishra points out, “The Indian industry has the potential to provide hardware, software and total solutions in the area of telemedicine. India can earn foreign exchange by marketing these products and providing solutions abroad. This area is totally untapped by the software industry.”

Nowadays there are increasing instances of patients from foreign countries coming to India to get treated in reputed hospitals here because of the lower cost. In future one may even see foreign hospitals coming to talk to Indian software players who specialise in the area of telemedicine. Whatever the outcome, the age of telemedicine has arrived in India.