Telehealth Report - India

Foreword 1

Editorial 2

Executive Summary 4

Telemedicon 2011 5

Telemedicine Concept 6

Telemedicine in India 17

Initiatives 32

Opportunities and Challenges 45

Industry Speaks 53

Business Models 58

Learning and Resources 60

Continua Health Alliance 65

Roadmap Ahead 67

References 71Co

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Telehealth Report - 2011with proceedings of

International Telemedicine Congress - 2011

India is presently building on its healthcare system, and the 12th Five Year Plan has been referred to as the ‘Plan for Health’ ! Now is the right time for the policy makers to ensure that technology is embedded in all programs that the Government is planning to rollout for healthcare delivery. In specific, mHealth has tremendous potential to reduce costs, improve the reach and access to healthcare, make the healthcare system more outcome driven, and more importantly, help in establishing an ‘empowered patient’.

With approximately 900+ million cell phones, healthcare in India will converge to mHealth, and ultimately, this is where all practitioners, payers and users will converge too! It is time to look at mHealth as a tool for ‘Inclusive Healthcare’ . Without mHealth,‘Universal Healthcare’ will just remain a dream !

Being personally involved in many mHealth & Telemedicine ventures and policy initiatives, I have always felt that when it comes to Telemedicine & mHealth, there is no concrete report that can fill in the readers with the detailed and up-to-date information, and so this attempt to come out with the first ‘Telehealth Report’- 2011. We have done our best to ensure that the report is accurate and full of facts from the users, policy makers and industry point of view. Still, this report could have inadvertent errors or short comings, as it usually happens with the so called ‘First Timers’. Please feel free to write back for any suggestions you might have .

I do hope that this report will be of immense help to users, providers and policy makers for mhealth & eHealth - not just in India, but across the world . I do look forward to your comments & feed back.

Yours in good health

Rajendra Pratap GuptaInternational Healthcare Expert & Chairman, Organizing Committee International Telemedicine Congress – Telemedicon’11

Member, Healthcare, Quality Council of IndiaPresident, Disease Management Association of IndiaChairman, Board of Directors, HIMSS Asia Pacific India ChapterCo-Chair, Sub-Group on Chronic Diseases, Confederation of Indian IndustryMember, Governing Council, Telemedicine Society of India Member, Board of Directors, Care Continuum Alliance, Washington, USA

Email : [email protected]

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Technological advancements have come a long way from the time of the great Industrial Revolution. What was initially feared for its negative consequences on society has emerged to be the culture of ‘Technological Utopianism’. Whether the technology boom can actually help realise this utopian environment or not, it sure has come to address many major issues across industries.

Industrialization has been marked by the coming together of two advancements, telecommunication and Information Technology, for bridging the technology gap between developed and the developing world. These powerhouses of global economy have been greatly accepted into the healthcare industry to aid in cure delivery, while paralleling the dynamic achievements made in medical sciences. As a form of Information and Communication Technologies (ICT), Telemedicine and mobile health are being largely employed across the globe to bridge the urban rural disparity in receiving care services. Telemedicine is best suited for nations like Africa and India, which have large populations in rural areas, devoid of quality care services and separated by great distances. Yet the adoption of these technologies is in its infancy. The industry as a whole needs to take the next step forward from the numerous pilot programs now underway to finding means of encouraging widespread roll out of Telemedicine and mHealth. The increasing use of internet and mobile phones across the globe, two of the basic requirements of Telemedicine, provides the industry ample impetus to advance this approach of care to a higher level. Improvements and advancements in telecommunication infrastructure and technology, the advent of high speed internet, improved connectivity, increased computer literacy and reduction in telecom service cost will further drive the industry. Furthermore, better privacy and security of confidential patient data and standardization of regulatory policies will form the pillars to remote provision of care services.

With so much interest being induced in this emerging area of healthcare, hopefully Telemedicine will transform itself into a self-sustaining economic environment. This congress, featuring the pioneers and innovators in the field of Telemedicine, was a platform for ideas and experiences to open into opportunities for immense growth and development in this area of healthcare that has already shown great potential and promise. I would like to congratulate Rajendra Pratap Gupta from the Telemedicine Society of India for organizing an event of this magnitude and coming out with India’s First Telehealth Report

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Dr. Sam PitrodaAdvisor to the Prime Minister of Indiaon Public Information and Innovations



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Telemedicine Society of India has exercised professional care and diligence in collection and processing of the information in this report.

However, the data used in the preparation of this report (and on which the report is based) was provided by third-party sources. This report is intended to be of general interest only and does not constitute professional advice.

Telemedicine Society of India makes no representations or warranties about the accuracy of the data in this report. Telemedicine Society of India is not liable to any user of this report or to any other person or entity for any inaccuracy of information contained in this report or for any errors or omissions in its content, regardless of the cause of such inaccuracy, error or omission. The quotations/views expressed in this report are those of the Industry leaders/speakers and do not necessarily represent views of Telemedicine Society of India.

Furthermore, to the extent permitted by law, Telemedicine Society of India, its members, employees and agents accept no liability and disclaim all responsibility for the consequences of you or anyone else acting, or refraining from acting, in relying upon the information contained in this report or for any decision based on it, or for any consequential, special, incidental or punitive damages to any person or entity for any matter relating to this report even if advised of the possibility of such damages.

© Telemedicine Society of India . Please do not copy or reproduce in whole or part thereof, the contents of this report without the written permission from [email protected]

For additional copies , please write to [email protected]

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y Despite a steady increase in the number of medical establishments and improvement in India’s healthcare infrastructure, much remains to be accomplished. There still remains a severe shortage of sub centres, primary health centres, and community health centres. While Telemedicine offers great opportunities in general, it could be even more beneficial for underserved and developing countries like India, where access to basic care is of primary concern. One of the biggest opportunities Telemedicine presents is increased access to health care. Providing populations in these underserved countries with the means to access health care has the potential to help meet previously unmet needs and positively impact health services.

Telemedicine applications have successfully improved the quality and accessibility to medical care by allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically developed countries. They can provide efficient means for accessing tertiary care advice in underserved areas. By increasing the accessibility of medical care, Telemedicine can enable patients to seek treatment earlier and adhere better to their prescribed treatments, and improve the quality of life for patients with chronic conditions.

Indian Telemedicine has come a long way since India's first Telemedicine centre at Apollo Aragonda Hospital was inaugurated in 2000. With its large medical and IT manpower and expertise in these areas, India holds great promise and has emerged as a leader in the field of Telemedicine. Key growth drivers include low cost of Telemedicine and wide reach over satellite or fiber optic bandwidth, lack of healthcare facilities in far-off regions, reduced technology cost and availability of qualified technical personnel, shortage of qualified medical professionals, and growth of ICT as a sector

Although there are many factors that are encouraging the adoption of Telemedicine as a medium of healthcare service, there are few challenges as well faced by the industry. Issues such as absence of global regulatory framework, lack of basic IT infrastructure, reimbursement policies, and legal constraints hinder the growth of the Telemedicine market. Lack of common standards and classification could pose a challenge to the growth of this market.

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Telemedicine Society of India organized the 7th International Telemedicine Congress, Telemedicon’11 from 11-13th November at Hotel Westin in Mumbai.

Telemedicon’11 was the ‘Biggest Healthcare Congress that has ever happened in India’. The event had an overwhelming response from one and all, which can be judged from the fact that all the exhibitor space was sold out weeks before the congress. The organizing committee members had to stop the registration process few days before the congress. Over 500 delegates from over 20 countries participated in the Telemedicine congress event held at Hotel Westin, Mumbai in India. Distinguished guests/speakers like Mr. Aneesh Chopra, CTO and Assistant to the President of USA; Shri Sachin Pilot, Hon’ble Minster of State for IT, Government of India; Dr. Prathap Reddy, Chairman, Apollo Hospitals Group; Shri Shankar Aggarwal, Additional Secretary, DIT, Government of India; Lord Nigel Crisp, Dr. Dale Alverson and a host of global healthcare leaders made this event a memorable one, and one of the biggest and most successful events in the Healthcare Industry. The entire Telemedicine ecosystem (telecom operators, telecom equipment manufacturers, mobile handset manufacturers, software vendors, policy makers, healthcare professionals) was present under one roof.

Telemedicon’11 has become an iconic conference in many ways as it has also launched the Continua Health Alliance on 13thNovember 2011, followed by an interoperability workshop, for the first time in India. About 40 Exhibition stalls were organized by the top players in Telemedicine to demonstrate their products/services.

In the current environment of shortage of healthcare professionals and greater incidence of chronic Ÿconditions, and rising healthcare costs, are driving the need to develop tools and solutions to improve healthcare delivery. One such tool is the electronic exchange of medical information, which is commonly referred to as Health Information Technology (“Health IT”). Health IT plays a key role in digitizing and transmitting health information electronically that can improve patient outcomes. Health IT processes can also include:

ŸUse of electronic health records by patients, physicians, insurers, hospitals and clinics

ŸHealth information exchange across industries and geographies

ŸUse of electronic health information to detect trends in population and publichealth

ŸTransmission of medication refills and a patient’s prescription history.

A key part of Health IT is increasing the frequency and use of technology-driven remote monitoring and consultation to treat patients. This area of Health IT is commonly referred to as “Telemedicine.” There is no universally accepted definition of Telemedicine.However, the American Telemedicine Association (ATA) defines the term as follows :

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It is a broad term within Health Information Technology that encompasses methods for electronically transmitting medical information. These methods can include store-and-forward technology for documents and images, remote monitoring of a patient’s vital signs, secure messaging, e-mail exchange of data, alerts and reminders between physicians and patients, and the ability to observe, diagnose and recommend treatment via videoconference. Telemedicine can eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities.

Closely associated with Telemedicine is the term ‘telehealth,’ with the former restricted to service delivery by physicians only, and the latter signifying services provided by health professionals in general, (including nurses, pharmacists, and others). Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of Telemedicine.

Major areas of Telemedicine include Teleradiology, Teleconsulting, Telemonitoring, & Telesurgery

Ÿ Teleradiology, is the transmission of radiological patient images, such as x-rays, CTs, and MRIs, from one location to another, for the purposes of sharing studies with other radiologists and physicians. Teleradiology is a growth technology given that imaging procedures are growing approximately 15% annually against an increase of only 2% in the Radiologist population

Ÿ Teleconsulting, is using Telemedicine for medical consultation.

Ÿ Telemonitoring, can be defined as the use of information technology to monitor patients at a distance.

Ÿ Telesurgery, (also known as remote surgery) is the capability for a doctor to perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence.

What is Telemedicine?

“Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status”

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mHealth

mHealth is a new area emerging within the field of Telemedicine. mHealth or mobile health is a term used in reference to using mobile communication devices, such as mobile phones and PDAs, for health services and information.

Nigel Crisp, Former CEO of NHS & Member, House of Lords

mHealth applications include the use of mobile devices in collecting community and clinical health data, delivery of healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vital signs and direct provision of care.

Products and Service Offerings

There are multiple industries that are involved in developing various applications of Telemedicine, including IT vendors, medical device manufacturers, pharmacies, hospitals, nursing homes, and venture capitalists. Accordingly, there are numerous products and services comprising Telemedicine.

Products : Many medical devices capable of collecting and electronically transmitting information can be digitized to be used in Telemedicine applications. These include blood gluc ose meters, pulse oximeters, blood pressure cuffs, spirometers, CT scanners, and MRI machines. Some of these devices are targeted towards home healthcare and the needs of patients interested in closely monitoring their health status, while others facilitate the exchange of information between hospitals, clinics and physicians.

Services : The use of medical products with electronic exchange capabilities allows for the provision of a wide range of Telemedicine-related services. These include st ore-and-forward technology for documents and images, remote monitoring of a patient’s vital signs, secure messaging, e-mail exchange of data, alerts and reminders between physicians and patients, and having a specialist remotely available by videoconference to observe and diagnose a patient’s condition and recommend treatment. Electronic exchange of prescription information between physicians, pharmacies and consumers is an additional service. Other Telemedicine services include transmitting information to alert communities about pandemics, and other widespread health threats.

Evolution of Telemedicine

Due to the recent advances in ICT, interest in Telemedicine has increased in the last few years. The concept is not new. The first reference of the subject is probably the famous “Radio Doctor” cover image of the 1924 Radion News Magazine. One of the first Telemedicine applications reported in the scientific literature was the project for transmission of radiologic images by telephone between West Chester and Philadelphia, Pennsylvania, covering a distance of 24 miles.NASA used Telemedicine in the 1960s as a way to monitor astronaut health on space missions.

Today, it’s used to electronically exchange medical information among patients, clients and health

providers, creating greater access to medical evaluation and improving patient care.

In the 1970s, the number of Telemedicine projects started to grow and the first real-time applications were mentioned. The STARPAHC Project tried to introduce Telemedicine in the rural Papago Indian Reservation in Arizona. Throughout the 1980s, Telemedicine specialty specific applications started to emerge, for example telepathology, which was first mentioned in 1986. The field of radiology saw the

“In UK, National Health Service (NHS) Direct started free health advice service over telephone. It has over six million subscribers, over 10% of the Country’s population.”

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Health IT

Telemedicine

mHealth

Chart 1: Health IT vs. Telemedicine vs. mHealth

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development of the first standard on digital medical imaging which culminated in the release of the DICOM specifications in 1992.

The number of Telemedicine applications started to grow rapidly in the 1990s due to the availability of internet, affordable computers and digital imaging solution. The lat est technical breakthrough in Telemedicine was probably the first transatlantic robotic operation which was performed in 2001 by a surgeon in New York on a patient in Strasbourg.

At present, electronic medical data, such as high resolution images and live video, are transferred through a v ariety of t elecommunication technologies, from fiber optics and satellites, to a simple telephone line. A growing number of medical specialties rely on Telemedicine to serve patients in areas such as adult rehabilitation, dermatology, emergency services, home healthcare, nephrology, pathology, paediatrics, perinatology, primary care, psychiatry, and radiology.

Current Deployment Scenario

In 2010, World Health Organization (WHO) conducted a survey to obtain an impression of the current state of Telemedicine service provision as well as four of the most popular and established areas of Telemedicine. 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), ‘informal’ (services not part of an organized program) or ‘no stage provided’ (services not part of any platform).

The survey examined four fields of Telemedicine :

1.Tele -radiology: 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.

2.Tele-pathology: Use of ICT to transmit digitized pathological results (e.g. microscopic images ofcells) for the purpose of interpretation and/or consultation

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The idea of performing medical examinations and evaluations through the telecommunication network is not new. Shortly after the invention of the telephone, attempts were made to transmit heart and lung sounds to a trained expert who could assess the state of the organs. However, poor transmission systems made the attempts a failure.

Ÿ1906 ECG Transmission: Einthoven, the father of electrocardiography, first investigated on ECG transmission over telephone lines in 1906

Ÿ1920s 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

Ÿ1924 The first exposition of Telecare: Perhaps it was the cover of "Radio News" magazine of April 1924. The article even includes a spoof electronic circuit diagram which combined all the gadgets of the day into this latest marvel

Ÿ1955 Telepsychiatry: The Nebraska Psychiatric Institute was one of the first facilities in the country to have closed-circuit television in 1955. In 1971, the Nebraska Medical Centre was linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns

Ÿ1967 Massachussetts 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 travellers

Ÿ1970s 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

Telemedicine



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4.Tele-psychiatry: Use of ICT for psychiatric evaluations and / or consultation via video and telephone.

Tele-radiology is currently the most developed Telemedicine service area globally, with 62% of responding countries offering some form of service and 33% of countries having an established service (Table 1). While the proportion of countries with any form of service ranged from almost 41% for teledermatology and telepathology, to 24% for telepsychiatry, the proportion of countries with established services in those three areas was comparable at approximately 15%.

Nigel CrispFormer CEO of NHS and Member, House of Lords

Telemedicine in developing countries

While Telemedicine offers great opportunities in general, it could be even more beneficial for underserved and developing countries where access to basic care is of primary concern. One of the biggest opportunities Telemedicine presents is increased access to health care. Providing populations in these underserved countries with the means to access health care has the potential to help meet previously unmet needs and positively impact health services.

Telemedicine applications have successfully improved the quality, and accessibility to medical care by allowing distant providers to evaluate, diagnose, treat, and provide follow-up care to patients in less-economically developed countries. They can provide efficient means for accessing tertiary care advice in underserved areas. By increasing the accessibility of medical care, Telemedicine can enable patients to seek treatment earlier and adhere better to their prescribed treatments, and improve the quality of life for patients with chronic conditions.

Telemedicine has been advocated in situations wherein the health professional on duty has little or no access to expert help, with need to offer remote physician access to otherwise unavailable specialist opinions, thereby providing reassurance to both doctors and patients. Telemedicine programs have been shown to directly and indirectly decrease the number of referrals to off-site facilities and reduce the need for patient transfers. Remote care and diagnosis via Telemedicine in less-economically developed countries thus benefits both patients and the health care system by reducing the distance travelled for specialist care and the related expenses, time, and stress. Furthermore, Telemedicine programs have the potential to motivate rural practitioners to remain in rural practice through augmentation of professional support and opportunities for continuing professional development.

“Telemedicine has done well, but the difference is not visible to the audience. In order to make the difference visible, we need to bring examples of real health and economic benefits that Telemedicine provides”

Service areas in Telemedicine Pilot Informal No Stage Provided TotalEstablished

Teleradiology 20% 7% 2% 62%33%

Telepathology 11% 9% 4% 41%17%

Teledermatology 12% 7% 3% 38%16%

Telepsychiatry 5% 5% 1% 24%13%

Table 1: Teleradiology – Most developed

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With progress in technology, the expansion of Telemedicine in developing countries is promising, one factor being the falling costs of ICTs. Other factors include increasing computing speeds, options for high-speed bandwidth and the falling costs of digital storage. Already basic store-and-forward e-mail-based Telemedicine requires minimal investment in hardware and software where network connectivity is available, and allows for detailed exchanges by enabling the transfer of images as attachments, making it an effective solution for low-resource settings. The growing development of Internet-based conferencing (particularly through no-cost software) increases the accessibility and portability of conferencing and counters the need for expensive video conferencing equipment that may be limited by availability. Low bandwidth, Internet-based Telemedicine (e.g., store and forward, e-mail-based consultations) has also proven to be a cost-effective technology that can efficiently and effectively pre-screen patients living in remote areas. By enhancing the information communication technology infrastructure and developing better communication facilities, Telemedicine can also add to the better management of scarce medical resources and day-to-day activities in the developing world.

What is holding Telemedicine in developing countries?

Barriers in realizing true potential

Infrastructure in developing countries is largely insufficient to utilize the most current Internet technologies. This lack and inadequate access to computing are barriers to Telemedicine uptake for many developing countries. At the most fundamental level, the variability of electric power supplies, widespread unavailability of internet connectivity beyond large cities, and information and communication equipment that is not suitable for tropical climates impose limitations on where Telemedicine can be implemented. Unreliable connectivity, computer viruses, and limited bandwidth continue to present challenges when and where Internet access is available. Internet congestion can lead to delayed imaging; poor image resolution may limit the efficacy of remote diagnosis; and slow bandwidth can prohibit the use of real-time videoconferencing. Even when basic infrastructure is in place, widespread interoperability standards for software are lacking and equipment or computer system failure remains an ever-present possibility.

Financial cost also poses both a real and perceived barrier to the application and adoption of Telemedicine in developing countries. Equipment, transport, maintenance, and training costs of local staff can be daunting for countries with little income or limited funding for the implementation and maintenance of Telemedicine initiatives. Moreover, convincing evidence to support the overall cost-effectiveness of particular Telemedicine strategies may be weak, while the economic implications of such strategies in different settings may not yet be known.

Local skills, knowledge, and resources may also limit the application of Telemedicine in developing countries. A lack of computer literate workers with expertise in managing computer services, combined with the lengthy process required to master computer-based peripheral medical instruments, can hinder uptake. While there may be a demand for distance learning, meeting local educational needs can be difficult due to differences in the diagnostic and therapeutic resources available, as well as the literacy and language skills across multiple sites. Moreover, while Telemedicine may enhance expert diagnosis, treatment options available are constrained by logistical challenges, including the training of local medical personnel, availability of medical equipment and supplies, and getting medicines to patients.

Socio-cultural differences between sites can limit the pertinence of Telemedicine collaborations in the developing world and challenge cultural perspectives related to health and wellness. A major contributing factor to Telemedicine failure is the oversight of incompatible cultural subsystems that prevent the transfer of knowledge from one cultural context to another. Medical professionals in the industrialized world may be unfamiliar with the available facilities and alternative management strategies in remote areas and vice versa. Telemedicine, therefore, risks the exchange of inappropriate or inadequate medical information. Without a good understanding of the local context, it may be difficult to integrate Telemedicine in a useful way.

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Lack of information available regarding legal policies, guidelines, or minimum standards concerning the use of Telemedicine in the clinical context can also prevent the adoption of such technologies.

Cross-border legalities are a concern for developing countries that use Telemedicine services to connect with health professionals from more than one country. An overall lack of evaluation data, trials, and published results concerning Telemedicine initiatives in developing countries has limited the amount of evidence on the impact and effectiveness of Telemedicine.

Complete evaluation is vital to systematically document best practices and lessons learnt from country-specific Telemedicine networks. Such evaluations will show which networks demonstrably alter health outcomes, prove to be cost-effective and are sustainable. These can then provide a model for other countries to adapt in their own contexts. Critical success factors include; clear program goals, garnering government and institutional support, adapting existing user-friendly interfaces, determining accessibility and connectivity constraints, implementing standards and protocols, and disseminating evaluation findings.

Where can Telemedicine help?

Application

The healthcare-at-a-distance concept has been adopted to overcome distance barriers and improve access to healthcare services. Telemedicine is being applied to enable:

Remote consultation: With Telemedicine, rural areas benefit from the same specialized services availed in urban areas. With the help of telecommunication and the internet, the technology has also been used to deliver care services to workers at oil rigs, passengers on board public transport, patients in transit, for medical tourism, and correctional systems.

Home care: This application of Telemedicine has been driven by the rise in chronic conditions, aging populations, scarcity of hospital streambeds, and the current global focus of empowering patients with their own health. In support of Telemedicine technology, the delivery of care has evolved to include connected care; a care model that exploits the use of technology to provide healthcare remotely. Telemedicine is between provider and recipient, and forms a medium by which information is transmitted. This is facilitated by two basic approaches that are applied in various scenarios:

1. Real Time (synchronous), when the exchange of information is immediate, and both the provider and recipient are present simultaneously at each of their ends. An example of the synchronous type is the usage of video conferencing for Telemedicine application.

2. Store and Forward (asynchronous), where the information is acquired and stored in a particular format before it is sent for expert consultation, as in the case of using e-mail for exchange of information.

The clinical applications of Telemedicine can also be categorized according to the different levels of technology maturity.

Mature: The most mature applications of Telemedicine are in the areas of teleradiology and telepathology. The primary reason for these disciplines of medicine to adopt Telemedicine is the similarity between the two. It is a known fact that radiologists and pathologists rely extensively on imaging technology rather than direct contact to diagnose a condition. Hence, the practice of diagnoses through Telemedicine would not substantially differ from conventional mode. This is one of the most prominent reasons as to why radiologists and pathologists were the earliest adopters of this technology.

Maturing: Maturing applications include telepsychiatry, teledermatology, telecardiology and teleophthalamology. Although there has been significant research interest in these areas, they are yet to receive institutional and professional acceptance globally, as there is a need for technology development, testing and dissemination, clinical guidelines and standards.

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Emerging: The emerging applications have been telesurgery, telepediatrics and emergency medicine. Telesurgery has been making steady progress in the areas of remote surgery and teleconsultatative processes in view of advancements made in robotics and related technologies, as well as broadband. This arm of Telemedicine has been researched for telemonitoring (surgical instructions), and teleproctoring (overseeing a surgical procedure). Majority of research and the development in telepediatrics is focused on treating children with chronic illness and special needs. School based telepediatric services for underprivileged children is another area that has shown potential for mainstream application.

How can Telemedicine help?

Rationale

There are several benefits that can be realized by an increased use of Telemedicine as also there are multiple factors driving the need for Telemedicine. Benefits can range from increased compliance in taking medications, to improved healthcare delivery in rural and underserved areas, to improved delivery of healthcare services outside hospitals and clinics, and better utilization of healthcare professionals.

Manage chronic diseases effectively: Chronic conditions such as diabetes, congestive heart failure, and obstructive pulmonary disease, require long-term treatment and use of multiple specialists, all of which significantly increase costs. Widespread Telemedicine adoption allows vital sign information and monitoring to be gathered frequently (instead of only during periodic physician visits). Messages can then be simultaneously transmitted to the treatment team, allowing for possible early intervention (a physician or hospital visit) if a patient’s condition deteriorates.

Extend reach to underserved/rural communities: Many regions of the world (both urban and rural) do not have a full range of healthcare services available. The presence of Telemedicine services in rural areas has been shown to improve care by decreasing transportation costs, more efficiently deploying healthcare professionals and specialists, and offering timely healthcare delivery without the obstacles presented by lakes, forests and mountains.

Address shortages of healthcare professionals: Telemedicine services such as videoconferencing and remote consultations, better utilize current staff, whether at a hospital, physician’s office, or via home-care. The availability of Telemedicine technologies and procedures can also allevia te potential shortages of healthcare professionals by enabling remote consultations by physicians and nurses for patients located in other states or countries.

Improve competitiveness of industry by controlling healthcare costs: With rising healthcare costs, Telemedicine can provide a tool for companies and insurers to better control and manage healthcare spending by enabling greater use of remote monitoring of a patient’s condition to minimize the need for acute care intervention, and more efficient deployment of healthcare professionals.

Empower patients regarding their own health: Raising the responsibility level of patients to take their medicines and report basic health metrics to their physician by using Telemedicine represents an opportunity for patients and caregivers to play a greater role in their own care.

Improve care of elderly, home-bound, and physically challenged patients: Use of Telemedicine to reduce the frequency of visits to physician offices and hospital emergency rooms can potentially lead to greater convenience and compliance for elderly and home-based patients.

Improve community and population health: Electronic sharing of image s and video consults, a component of Telemedicine, permits easier exchange of information between public health services about a rare or unusual health condition, better measure chronic diseases in a population, or address a public health crisis.



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Reduce deaths, injuries, and infections: Increased use of Telemedicine across all settings could reduce the incidence of adverse events caused by treatment and medication errors arising from piece-meal or inaccurate patient information, leading to more consistent patient treatment by limiting the number of hospital visits and reducing exposure to illness from other patients. In addition, electronic prescribing can help reduce errors in dispensing medicines by eliminating the need to decipher handwritten prescriptions.

Global Telemedicine market

The global Telemedicine industry has been growing remarkably and expanding virtually across all the medical areas for the past few years. The global market for Telemedicine was valued at USD 9.8 billion in 2010, and it is expected to grow at a CAGR of 18.6% to reach USD 23 billion by 2015.

The global telehospitals/clinics market in 2009 was USD 5.6 billion and accounted for approximately 71% of the total Telemedicine market. This sector is valued at USD 6.9 billion in 2010 and is expected to reach USD 15 billion in 2015, at a CAGR of 16.8%.

The telehome market, which represented approximately 29% of the Telemedicine market in 2009, is expected to contribute 34.7% by 2015. This segment was valued at nearly USD 2.9 billion in 2010 and is expected to reach USD 7.9 billion in 2015 at a CAGR of 22.5%.

One of the key factors contributing to this market growth is federal grants offered in the USA. The global Telemedicine market has also been witnessing an increase in strategic partnerships. Healthcare organizat ions are adopt ing Telemedicine technologies to cater to the demand for healthcare services. Other key growth drivers include shortage of health professionals, ageing population, availability of application service provider model, and affordable broadband internet access.

Growth prospects of the Telemedicine market vary according to geographies. USA and Europe dominate the world Telemedicine market. USA has witnessed deployment of numerous federal grants during the past few years, which has aided in the excessive growth of the Telemedicine market in the country. Europe, on the other hand, has been witnessing a strong demand for Telemedicine products due to the rise in aging population and enhanced requirements for home treatments.

Asia is the fastest growing region. It exhibits huge growth potential in the coming years as Telemedicine demand in this region will be driven by rising healthcare costs. There is a substantial rise in demand for Telemedicine in China and India. As governments and private players have stepped into the industry across most of the geographical locations, the future prospects of the market show immense opportunities to tap into.

Although there are many factors that are encouraging, the adoption of Telemedicine as a medium of healthcare service, there are few challenges as well faced by the industry. Issues such as absence of global regulatory framework, lack of basic IT infrastructure, reimbursement policies, and legal constraints hinder the growth of the Telemedicine market. Lack of common standards and classification could pose a challenge to the growth of this market.



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CAGR 18.6% (2010-2015 )

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Telehospitals / clinics Telehome

2009 A 2010 A 2015 E

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As Telemedicine has the potential to improve both the quality and the access to health care regardless of the geography; the rural market is driving the incessant growth of the Telemedicine market. Without Telemedicine, access to primary care services would remain strained or nearly impossible for numerous rural patients. In the coming years, Telemedicine will not only assuage the inaccessibility that rural practitioners and patients experience, but it will also broaden the range of services to the rural residents.

Other trends observed globally include adoption of 3G and High Speed Package Access (HSPA), increasing use of wireless and web-based services, integration of various devices such as patient alert devices and vital signs recording devices, and hospitals’ integrated approach to healthcare delivery.

Case Studies

Mobile phones for health

Application Area : Remote monitoring

In 2005, engineers at Loughborough University developed a mobile phone health monitoring system to monitor diabetes and other diseases. The system allows doctors to use mobile phone networks to monitor up to four key medical signals (electrocardiogram heart signal, blood pressure, levels of blood glucose, and oxygen saturation levels) from patients who are on the move. Engineers from the UK and India are working to ‘miniaturize the system’ so that sensors are small enough to be carried by patients while procuring the necessary biomedical data. In Britain, the solution will be used to improve healthcare delivery, while in India it will connect ‘centres of excellence’ to hospitals and clinics in more remote areas. Over the next three years, clinical trials will occur in both the UK and India.

Ÿ UK-based Loughborough University's engineers entered into a partnership with India to develop a unique mobile phone health monitoring system.

Ÿ The system, which was first unveiled in 2005, uses a mobile phone to transmit a person's vital signs, including the complex electrocardiogram (ECG) heart signal, to a hospital or clinic anywhere in the world.

Ÿ Presently, the system can transfer the signals pertaining to the ECG, blood pressure, oxygen saturation and blood glucose level.

Ÿ IIT, Delhi, the All India Institute of Medical Sciences and Aligarh Muslim University and London's Kingston University joined hands to further develop the system.

Ÿ The research team is aiming to miniaturize the system by designing sensors and mini-processors that are small enough to be carried by patients, and at the same time procure biomedical data. The network of sensors would be linked through a modem to mobile networks and the Internet, and to a hospital computer. Then, doctors can use this device to remotely monitor patients suffering from chronic diseases, like heart disease and diabetes.

Ÿ The clinical trials of the system are going on in the UK and India.

Support to Promote Maternal and Newborn Health

The aim of the Telemedicine Support to Promote Maternal and Newborn Health in Remote Provinces of Mongolia project is to reduce infant and maternal mortality while addressing the gap between urban and rural healthcare services. The project started in September 2007 and continued till December



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2010. Telemedicine services supported Aimags (province), with high-risk pregnancy consultations, prenatal ultrasound diagnostics, foetal monitoring and screening for cervical abnormalities using colposcopy. The services provided by the project were particularly important for women in remote rural regions who do not have the funding to travel for expert opinion.

A total of 297 doctors, nurses and midwives were trained for this program between March and December 2009. A total of 598 cases were referred in 2009. Of these, 64% were obstetrical, 21% were gynaecological pathology and 15% were neonatal pathology. Only 36 of these cases were referred to Ulaanbaatar for treatment following the diagnosis, substantially saving the resources of rural residents that would otherwise have gone towards travel expenses.

Opportune Breast Cancer Screening and Diagnosis Program

In 2006, breast cancer became the leading cause of death among Mexican women between the age groups of 50 to 69. The Opportune Breast Cancer Screening and Diagnosis Program (OBCSDP) was meant to transcend economic and personnel barriers through the innovative deployment of ICTs. Aimed to reduce the breast cancer mortality rate in women, the program increased the national screening rates from 7.2% in 2007 to 21.6% by 2012.

The Telemedicine network has a goal to screen 1.3 million women in a 30 month period between May 2010 and December 2012. With over 34 million Mexican pesos (USD 2.8 million) of seed funding from the federal and state governments as well as not-for-profit groups, 30 screening sites in 11 states were linked by internet to two interpretation centers where results of the screenings could be viewed by radiologists.

Due to challenges with internet connectivity in rural areas of Mexico, many Mexican communities lack the necessary bandwidth for internet protocol-based image transmission (necessary to transmit mammograms). To overcome this challenge, CDs were used for patient data transfer and long-term data (backup) storage. (Each carried four patient images (a full mammography) and up to four patient mammograms). CDs were privately or commercially couriered to the closest interpretation centre. However, results with this method took up to three weeks to be returned to individuals.

Text to Change

Sponsoring Organization and Partners: Celtel, AIDs Information Centre (AIC), Merck, and the Dutch

Ministry of Foreign Affairs. Text to Change (TTC) program provided HIV/AIDS awareness via SMS based

quiz to 15,000 mobile phone subscribers during three months in Uganda. TTC was founded with the

goal of improving health education through the use of text messaging, which holds the advantages of

anonymity and strong uptake among the population. Partnering with the mobile carrier Celtel and the

local NGO AIDS Information Centre (AIC), TTC conducted a pilot program from February till April 2008 in

the Mbarra region of Uganda, with the objective of increasing public knowledge of and changing

behaviour regarding AIDS. The program aimed to encourage citizens to seek voluntary testing and

counselling for HIV/AIDS. Free airtime was offered to users to encourage participation in the program.

This was determined to be a powerful incentive since users could exchange the airtime with other

subscribers as a type of currency.

The quiz was interactive. When participants gave a wrong answer they received an SMS with the correct answer from the cell phone provider. The uptake rate of the survey was 17.4%. The quiz focused on two specific public health areas:

Ÿ General knowledge about HIV transmission, and

Ÿ Benefits of voluntary testing and counselling.



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At the end of the quiz, a final SMS was sent to motivate participants to go for voluntary testing and counselling at the local health centre. Those who went to the centre were asked a final question: Was this the first time they had an HIV test? After testing, participants were requested to leave their mobile phone number so that post-test counselling could be arranged. For the people who came to the health centres through TTC, HIV testing and counselling was free of charge. Initial grants from Merck, the US pharmaceutical company and the Dutch Ministry of Foreign Affairs supported the program launch.

Bringing critical pediatric care to a rural hospital

Intel announced a comprehensive set of digital inclusion projects aimed at improving education, healthcare and economic development for Nigeria's 140 million people in 2007. With the support of the Federal Ministry of Health, Intel launched a pilot Telemedicine project that brings critical pediatric care to a rural hospital serving a region of 4.5 million people. They are now able to consult in real time with pediatric and surgical specialists in Abuja through the new Telemedicine system, which features video conferencing and high-speed broadband connections through Wimax (a long-range wireless technology). The pilot makes it possible for physicians to shorten both time and distance in getting to patients to treat them. The system connects one of Nigeria's leading medical institutions, the National Hospital in Abuja with the Federal Medical Centre in Bida, a rural 200-bed medical facility. Till now, patients who needed referrals from Bida were forced to travel at least 250 kilometres to reach specialists, a trip most could not afford. Bida has an acute need for care from pediatric medical specialists. In the project's first phase, a foetal monitoring capability will permit pediatrician to remotely and more quickly consult with medical staff and examine expectant mothers to monitor the progress of their pregnancies. Intel is also training medical practitioners and technical specialists at both hospitals to use the new technology tool.



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The healthcare model in India is a three tier system. At the first tier are the primary centres and sub-centres that provide services at the village level. The secondary level comprises healthcare facilities located at the district level, which includes district hospitals, private clinics and small nursing homes with limited equipment and expertise. The third tier or tertiary level healthcare settings are through medical college hospitals, specialty, and super specialty private chains of hospitals generally located in urban areas. Besides, there are a few advanced medical institutes of national importance, having clinical, teaching and research facilities in various super specialties. Primary level includes Primary Healthcare Centres (PHC’s) and sub-centres at the village level equipped with a practitioner and facilities to provide first-aid or basic medical check-ups. However, many centres lack qualified practitioners, adequate medical supply, specialty solutions, connectivity and medical beds, etc. Secondary level includes District level hospitals, small private clinics and nursing homes with small equipment and facilities limited to providing basic medical diagnosis. However, In India they too lack specialty treatment facilities, high-end medical equipment and adequate number of beds.

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Health care model in India

Primary centers and sub-centers that provide services at the village level

Healthcare facilities located at the district level including district hospitals, private clinics & small nursing homes with limited equipment and expertise

Medical college hospitals, specialty, and super specialty private chains of hospitals generally located in urban areas

Tier-1

Tier-3

Tier-2



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Tertiary level includes medical colleges, big private chains of hospitals and corporate hospitals situated in large urban areas. Facilities include high-end medical equipment, well qualified medical staff, etc. These institutions, however, service a small segment of the vast population of the country.

Despite a steady increase in the number of medical establishments and improvement in India’s healthcare infrastructure, much remains to be accomplished. There still remains a severe shortage of sub centres, primary health centres, and community health centres. Lack of adequate healthcare is also reflected in the low density of healthcare personnel. India does not have a national health insurance policy or any other national healthcare guarantee program for its citizens. The existing three tier health care system is highly inadequate in providing quality healthcare services due to India’s increasing population and the growing demand for healthcare services. Growth in physical infrastructure i.e., healthcare facilities and hospitals is not sufficient to meet the current demand.

The poor state of healthcare system in India may also be attributed to the lack of government funding on healthcare initiatives. As estimates reveal, per capita spending on healthcare by the Indian Government is far below international recommendations. The healthcare spend, when compared on the basis of public-private contribution, also depicts a skewed picture. Private sector contribution to the healthcare at approximately 74% is amongst the highest in the world. Public spending, on the other hand, is amongst the lowest in the world and is approximately 26% points lower than the global average.

Indian Healthcare Market

The Indian healthcare sector represented a USD 40 billion industry in 2009. Hospitals accounted for approximately 50% of the market, pharma contributed 25%,diagnostics with 10%, and medical equipment accounted for roughly 15%. The industry is expected to grow to USD 79 billion by 2012 and USD 280 billion by 2020 at a CAGR of 21.5%.

The Healthcare sector, in India, is at an inflection point and is poised for a healthy growth in the medium term. Healthcare spending is expected to grow to 8% of the GDP in 2012.

A combination of demographic and economic factors is expected to bring increased healthcare coverage in India which is expected to drive the growth of the sector. India‘s rising population and income levels, along with a growing preference for private health services over public services, is augmenting the growth of the healthcare delivery market. Population growth and increased disposable income are expected to result in better healthcare awareness and more expenditure on healthcare.



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Indian healthcare spend as a % of GDP is less than half the global average

Chart 3: Healthcare spending as a % of GDP, 2007

%

20

15

10

5

0GlobalIndia China UK Brazil US

Per Capita spending as compared to other Countries is also very low in India

Chart 5: Per Capita Healthcare spending, 2007

USD8,0007,0006,0005,0004,0003,0002,0001,000

0US UK Brazil China India Global

Public healthcare spending in India is again half the global average, amongst the lowest in the world

%

100

80

60

40

20

0GlobalIndia China UK Brazil US

Chart 4: Public spending as a % of total healthcare spend, 2007

%

300

250

200

150

100

50

0

CAGR 21.5% (2010-2020 )

2010 A 2012 E 2020 E

Chart 6: Healthcare industry in India

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Healthcare expenditure (public and private) in India is expected to increase by 15%. India has the

potential to add nearly 1.74 million beds by 2025 with an investment of about USD 104 billion to fulfil

the unmet needs. The demand for quality healthcare in India is burgeoning and there exists a huge

supply gap. An additional 1.74 million beds are needed to achieve the target of two beds per 1,000

populations by 2025. An additional 700,000 doctors will be required by 2025 to reach a ratio of one

medical doctor per 1,000 individuals. To maintain the current doctor-to-nurse ratio of 2.2, an additional

1,600,000 nurses will have to be trained by 2025.

Population of India is expected to increase from about 1.21 billion in 2010-2011 to 1.4 billion by 2026. In

addition, an expected increase of geriatric population from current 96 million to around 168 million by

2026 represents a huge patient base and creates a market for preventive, curative and geriatric care

opportunities.

Households can benefit from an increase in disposable income from 14% in 2009-2010 to 26% in 2014-

2015 making healthcare more affordable. There is likely to be a marked increase in the incidence of

lifestyle-related diseases, such as cardiovascular, oncology and diabetes, when compared to the

communicable and infectious diseases. Growing general awareness, patient preferences and better

utilization of institutionalized care is expected as a result of increase in literacy rates. Lower direct taxes,

higher depreciation on medical equipment, income tax exemption for five years to hospitals in rural

areas, etc. are being provided by the Government to the sector to boost it. India is also emerging as a

major medical tourist destination with medical tourism market expected to reach USD 2 billion by 2012.

Telemedicine – Promising Future

Telemedicine can embrace modern technology to widen healthcare accessibility in rural India and

can be a solution for India’s healthcare woes. A vast country like India, with a population of over 1.2

billion across 29 states and 6 Union Territories and governed by a federal system, needs affordable

healthcare.

Rajendra Pratap Gupta, Leading Global Healthcare Policy expert

Telemedicine today has given the ability to the doctors to provide healthcare to the needy. It is taking

modern healthcare to remote areas. Majority of diseases not requiring surgery are conducive to

Telemedicine. It allows training of medical personnel across the country to provide services to the

patients in remote areas. Over the last five years; both price and complexity of this technology has

decreased making Telemedicine economically viable. Telemedicine, as a branch of diagnosis and

treatment, should be encouraged and widely implemented to help ensure availability and accessibility

of care to all areas in spite of infrastructural inefficiencies.

“It is a fact that has not been accepted by policy makers that it is nearly

impossible under the current rural infrastructure and payment terms to

get good doctors to work in rural India. In addition, building healthcare

facilities and maintaining them in rural India is financially unviable. So the

current healthcare system will always be an ad hoc arrangement and a

highly subsidized one while not being a lasting solution. Rural India needs

to extensively leverage the 3G and WIMAX technology and adopt

preventive care model to avoid pain, suffering and high cost of

healthcare”



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Telemedicine is the convergence of communication technology,

information technology, biomedical engineering and medical

science.

In India, early forms of Telemedicine used telephone and radio

followed by communication through fiber optic cables. Lately,

Telemedicine has evolved to utilizing video telephony, advanced

diagnostic methods supported by distributed client/server

applications, and telemedical devices to support medical care at

homes. This evolution in Telemedicine is through satellite

communication developing from ‘Point to Point System’ (one

remote location connected to one main location) to ‘Point to Multi

Point System’ (one remote location at a time connected to many

main locations), and finally to ‘Multi Point to Multi Point System’

(several remote locations simultaneously connected to main

locations in different geographical locations).

Video Conferencing

District HospitalSpecialty Hospital

Panel of Doctors

Chart 8: Representative Telemedicine structure

Remote Location

Ÿ Regional/secondary care hospitals

Ÿ Rural health care services

Ÿ Primary care

Ÿ Consultation and diagnosis

Ÿ Patient education and follow-up

Ÿ Professional education

Ÿ Continuing medical education

Ÿ Administrative services

Main Location

Ÿ Regional/tertiary care hospital

Ÿ Consultation

Ÿ Screening and diagnosis

Ÿ Monitoring

Ÿ procedure guidance

Ÿ Patient education & follow-up

Ÿ Professional education

Ÿ Continuing medical education

Ÿ Administrative services



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Medical Science

Communication Technology

Biomedical Engineering

Telemedicine

Information Technology

Chart 7: Pillars of Telemedicine

The Telemedicine system comprises of customized hardware and software at the “Patient” site and the “Specialist doctor” site, with diagnostic equipment like ECG, X-ray, Pathology, Microscope/Camera, etc. provided at the patient end. They are connected through a Very Small Aperture Terminal (VSAT), WIFI, and Broadband, controlled by a Network Hub Station. Through a Telemedicine system that consists of a simple computer with communication systems, the medical images and other information pertaining to the patients can be sent to the specialist doctors, either in advance or on a real time basis through the satellite link in the form of Digital Data Packets. These packets are received at the specialist centre, the images and other information are reconstructed so that the specialist doctor can study the data, perform diagnosis, interact with the patient and suggest the appropriate treatment during a Video Conference with the patient end. Telemedicine facility thus enables the specialist doctor and the patient, separated by a distance, to interact visually and talk to each other.

Major components of Telemedicine include :

Ÿ Telemedicine workstation

Ÿ Document and radiographic film digitizer

Ÿ Ultrasound device, ECG, MRI, Scanner, X-Ray

Ÿ Processing unit and keyboard

Ÿ Audio Module – speakers, headphones, volume and base control

Ÿ Camera - lens, image sensor, pixels, resolution, illumination range, video output signal, power zoom

Ÿ Microphone

Ÿ Monitor – resolution, speakers, signal type, dot pitch

Ÿ Central power switch, power requirements

Ÿ Communication platform allowing compatibility with networks (WAN) – SW-56, ATM, ISDN,satellites, and networks (LAN) - Ethernet

Ÿ Connector panel – LAN, WAN, phone network, audio and video input and output ports, radiographic film digitizer, CD-ROM, etc.

Ÿ Telemedicine peripheral devices – Otoscope, Dermatoscope, Stethoscope, Ophthalmoscope, etc.

Ÿ Telecommunication network architecture

Ÿ Plain Old Telephone System (POTS) - Analog telephone lines

Ÿ Dial-up digital telephone lines - Integrated Service Digital Networks (ISDN) and Switched-56 (SW-56)

Ÿ Asynchronous Transfer Mode (ATM)

Ÿ Satellite – Geo-synchronous and Low Earth Orbit (LEO)

Ÿ Microwave

Ÿ Coaxial Cable, Fibre Optics

Ÿ Asymmetric Digital Subscriber Line (ADSL)

Ÿ Various Digital Subscriber Line (xDSL)

Ÿ Internet or Modem

Ÿ Virtual Private Networks

Ÿ Hospital and Regional Health Networks

ŸSoftware Architecture

ŸHuman intervention

Ÿ Physicians – General practitioners, specialists and medical students, etc.

Ÿ Nurses – Registered Nurses (RN), Licensed Practical Nurses (LPN) and nursing students

Ÿ Allied Health Professionals – occupational therapists, physiotherapists, etc.

Ÿ Health Administrators, Educators and Researchers

Ÿ Technicians

Ÿ Patients and their families, informal care givers

Ÿ Telehealth project Managers and site coordinators.

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mHealthmHealth, also known as Mobile health, leverages mobile devices and ICT to deliver health services and information exchange which can increase access, affordability, and quality of healthcare significantly.



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Today’s Technology Tomorrow’s Technology

Hardware

Ÿ Features suitable for basic mHealth services available on mobile phones

ŸMobiles can access web, download pictures, etc.

Ÿ Internet speeds limit the number of applications which can be used

ŸMost laptops, handhelds, PDAs easily access wireless networks where available

ŸCell phones and mobile computers become less discrete

Ÿ Larger displays and Solar chargers for mobiles

Software and applications

ŸWidely available for laptop and handhelds

ŸAvailability of handsets with open architecture.

ŸOpen source software accelerate application development and reduce cost

Network access

ŸCellular usage common in urban areas compared to rural areas

ŸBroadband, internet access is limited in several geographies and also costly

ŸNetwork transparencyŸWireless networks create almost

universal Internet access

Standards

Ÿ Policies and standards required for Broadband

ŸAllowance of greater range of services, provider

Ÿ Partnerships

Services

Ÿ Education/awareness programsŸMedication monitoringŸData collection servicesŸDisease trackingŸRemote monitoring

Ÿ More sophisticated diagnoses/consultations, e.g., Teleradiology, teleopthamology.

Ÿ More effective use of healthcare workers

Ÿ More ‘personal’ mHealth services

Ÿ Services for travel-restricted

Chart 9: Mobile technology evolution

Technology advancement

WIMAX availability for Pcs

Open source systems

Greater bandwidth

IP access for standards and decisions over licensesI

Better services offerings

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Ÿ Improved treatment, education, and illness prevention

Ÿ Improved operational efficiencies, improved quality, and effectiveness of healthcare

ŸMore effective delivery of healthcare services

Ÿ Improved operational efficiencies

ŸOrganizational mission closely ties to program success

ŸExpansion or scale of program

ŸRevenue from hardware sales

ŸStrategic market positioning for short and long term brand and business development

ŸRevenue from training or supporting contracts

ŸOpportunities for placement in network expansion projects

ŸRevenue from service fees through increased subscribers

ŸRevenue from handset device sales

ŸExpanded mobile subscriber base for increased revenue from other services

ŸRevenue from application license fees

ŸRevenue from application customization fees

ŸRevenue from training contracts, hardware support system

ŸOpportunity to become a standard in mHealth

ŸPotential for add-on sales as program scales

Patient: Recipient of healthcare service

Caregiver: Delivering healthcare services like physicians, nurses, midwives, healthcare workers

Project management: The entity responsible for direct management of the project including business and programmatic, like a government agency or independent organization

Equipment provider: Generally the manufacturer of any hardware relative to the services including customer devices or network devices. May also provide training, support to operator or health care practitioner.

Service provider: The mobile telephony operator

Application Solutions provider: The entity providing mHealth application, either as a standalone software application or an integrated application

It involves the use and capitalization of a mobile phone’s core utility of voice and short messaging service (SMS), as well as more complex functionalities and applications including general packet radio service (GPRS), third and fourth generation mobile telecommunications (3G and 4G systems), global positioning system (GPS) and Bluetooth technology.

As 3G swings in India with over 900 million mobile phone connections and Android phones become increasingly available, the opportunity for high value mobile enabled services is tremendous. Two industries that have already tapped into the ubiquity of mobile phones in a big way are entertainment and financial services, with applications ranging from music downloads to banking that are attracting swaths of users and investments. But mHealth has only scratched the surface in India largely because there is a lack of awareness among patients and doctors about what mHealth is and what benefit it can provide.

Table 2: mHealth – A win-win for all



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Table 3: Overview of mHealth use case findings across the Healthcare Continuum

ŸAccessibility of patient data; reduction in procedures and tests; fewer medical errors

ŸImproved patient access to physicians; increased billable hours

ŸLower administrative costs; faster service

ŸImproved supply chain efficiency/accuracy; increased productivity; lower risk of compliance breaches

ŸAccurate and timely feedback to patients; ease of coordinating remote providers; streamlined consultations

ŸRegular patient monitoring; increased productivity; reduced travel time

ŸReal-time updates of patient data; ability to offer “untethered” care outside of traditional settings

ŸEase of locating specialists and services in network; lower costs with drug cost-comparison shopping; increased consumer usage of plan benefits; better management of medical expense accounts

ŸIncreased accuracy and lower costs; compliance-certified apps meet regulatory requirements

ŸCommunity-based retail stores use mobility to improve ACO care coordination

ŸReal-time access to data to advise doctors and patients on drug therapies and associated risks

ŸEnables pharmacists to interact with patients “in the aisles” with access to real-time patient data

ŸMore efficient and accurate order processing; improved compliance in sample distribution; digital signature capture

ŸAbility to identify and catalog worldwide epidemiologic trends

ŸInteractive apps to identify appropriate care providers

ŸAccurate and timely feedback of health data; rapid throughput of test results to providers

ŸImproved care/lower costs through home healthcare

ŸGreater emphasis on patient-centered care; reduced isolation of convalescing patients

ŸIncreased knowledge of cost/benefit trade-offs

ŸElectronic Health Records, Health Information Exchange

ŸTelehealth/remote careŸPatient self-registration using

tabletsŸBar code scanning


ŸTelehealth/remote care

ŸPeripheral devices integrated into mHealth solutions

ŸConsumer self-help apps

ŸMobile apps replace paper-based forms; bar code scanning

ŸDrug reference and drug interaction apps

ŸMobile access to back-office

ŸMobile CRM apps for “detail” sales representatives


ŸSymptom checker

ŸApps with integrated peripheral devices

ŸTelehealth/remote care

ŸSocial engagement-based solutions

Hospitals

Doctors, Nurses

Insurance Companies

Suppliers

Pharmacies

Drug and Medical Supply CRM

Federal Agencies

Consumers

dell

Sticky Note

Need to bring it below the line.

A February 2011 report authored by Pyramid Research found that more than 200 million mobile health applications are used by doctors and patients today, and more than 600 million medical apps will be available by 2012. (Source: Pyramid Research)

According to a February 2011 study by Aptilon, 79 percent of physicians prefer the iPad, compared with 12 percent of doctors who prefer a Windows-based tablet and nine percent who prefer an Android device.

An InfoWorld article published in May 2011 cites a study by RNCOS. The study estimates healthcare IT spending in the United States is expected to reach $40 billion in 2011. Of that, the mobile health market is estimated to be 5.3 percent of total healthcare IT spending.

Projections indicate that over one third of all smartphone holders worldwide or 1.4 billion people globally, will be using mHealth solutions within the next five years, according to research2guidance.

Through informal polling, Epocrates estimates up to 70 percent of medical schools are having a mobile device requirement or recommendation for medical students. The average physician can re-purpose 130 administrative hours each year by using a mHealth solution.

According to Galvin Consulting, August 2011, many healthcare professionals are looking to new mobility technologies as a way to solve some of the industry’s most pressing problems. These thought leaders believe society is on the cusp of dynamic change in the way healthcare is both provided and consumed. Mobility in the general workforce is expected to increase at an unprecedented rate in the coming years, both in the United States and other countries, including India.

In developing countries such as India, mHealth shows special promise in specific mHealth applications, including:

Ÿ Widespread care through telemedicine and “virtual hospitals”.Ÿ Improved medical data processing as a result of direct data input into mobile devices.Ÿ Improved patient care as physicians interact directly within local communities.Ÿ Early warnings of shifting health trends, including emerging and infectious diseases, as large

amounts of data from mobile devices are collected and analyzed.Ÿ Improved disaster response efforts for earthquakes, floods and other disasters as first responders

use mobile devices to identify areas most in need of assistance.

Over and above these benefits are improved accuracy throughout the healthcare system and earlier detection of medical issues that help to prevent expensive and serious complications later.

Current state of Telemedicine in India

Telemedicine practice was first initiated in Lucknow and Chennai in 1997. In Kerala, first unit of Telemedicine was formed at the Medical College, Thiruvananthapuram in 2003. Recognizing the common interest of health and community welfare, Telemedicine was promoted for the availability of quality medical services to the needy, irrespective of socio economic and geographic disparities like rural, remote, and inaccessible places.

During the National Conference on Telemedicine held in Lucknow in April 2001, the participants resolved to form a scientific society dedicated to Telemedicine at national level and carry out an annual scientific event pending a formal registration. Thus the Telemedicine Society of India (TSI) was born and all the participants signed a resolution to this effect and were made the founding members. It has been a long journey for the TSI. Although the efforts had started from 1996, yet it took time to reach this position. Having survived infancy, it is now coming of age. In all developing countries, there is an acute shortage of resources in the health care sector. In emerging economies like India, there has been an

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exponential and an unprecedented increase in the availability of Information and Communication Technology. ICT has provided a unique opportunity of bridging the urban rural health divide. For Telehealth to take off, it had to be embraced by all the stakeholders; the Government, private sector, public sector, entrepreneurs, etc.

The first TSI meeting was held in Lucknow in 2001. Its focus was on rural medicine. Initial support from ISRO played a very vital role in the growth of Telemedicine in India. The official TSI meet took place in Bangalore in 2005 when the smooth life of TSI began. Then the annual successive meets took place in Delhi (2006), Chennai (2007), Chandigarh (2008), Pune (2009), Bhubaneshwar (2010), and Mumbai (2011). The first TSI chapter was started in 2010 in Bhubaneswar. Over a period of time, TSI has extended their services to Indian army. They set up Telemedicine units initially in the southern command and subsequently in the central command. Training programs were organized exclusively for officers. They have also pioneered in partnerships with Uganda, Mauritius, Nigeria, the Netherlands, etc. As of now, TSI has provided teleconsultations in various specialties to 29 countries in Africa, and also initiated teleconferences with many countries including Japan, US, Saudi Arabia and Hong Kong.

India is beginning to make strides in the areas of Telemedicine and eHealth. Most of the Telemedicine activities are in project mode, supported by the ISRO and the Department of Information Technology and being implemented through state governments. A few corporate hospitals have developed their own Telemedicine networks, prominent among them being the Apollo Telemedicine Networking Foundation, which commenced Telemedicine operations as early as January 2000. Around 500 Telemedicine nodes are in place across the country.

Telemedicine has a market size of USD 70 – 110 million in India. It is expected to grow at very high CAGR of approximately 35% over the next five years to reach USD 314 – 493 million by 2016. The full potential of the Telemedicine market could be realized with appropriate stakeholder vision and better adoption. Key growth drivers are:

Ÿ Low cost and wide reach over satellite or fiber optic bandwidth

Ÿ Lack of disease management framework

Ÿ Lack of healthcare facilities in far-off regions

Ÿ Reduced technology cost and availability of qualified technical personnel

Ÿ Shortage of qualified medical professionals

Ÿ Increased government focus on healthcare for all

Ÿ Urban-rural divide causing disparity in medical facilities

Ÿ Dedicated satellite for health communications from ISRO

Ÿ Growth of Information and Communications Technology as a sector

Ÿ National Telemedicine grid to connect practitioners and institutions

Ÿ PPP model for development of healthcare infrastructure

The key growth driver for Telemedicine is India is its technologically advanced ICT sector which is self-sufficient in meeting its needs of hardware, software, connectivity and services. Therefore, ICT technologies have the potential of making healthcare affordable for India, especially in rural India. This success can be further reinforced if these ICT technologies are integrated into existing health-care delivery systems. In the last decade, there has been active investment for development of Telemedicine in India, but considering the demographic spread, this investment is not sufficient for such a large country. The scale of Telemedicine services in India has been limited so far to medical transcription, health awareness through portals, Telemedicine and hospital management system and customer service using the internet. While globally and particularly in Africa, advanced technologies such as 3G services are used efficiently for providing healthcare solutions to remote villages, the use of communication devices such as mobile phones or conferencing solutions for Telemedicine in India has been limited.

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“In the next 3-5 years, I can well foresee a fight between Tablets & Smart-Phones, a fight between Windows, Apple & Android rather than a fight between a user and non-user of mHealth.”

“mHealth is more relevant in India than conventional eHealth, as access to PCs, laptops and broadband is far less than access to mobile phones. India has just 12 million broadband connections, 24 million internet subscribers and 85 million PCs as compared to 881 million mobile phones.”

“It is not possible for everyone to own a computer or to use a computer for health, but smart phones comes in handy, and so, for sure, a l l aspects of healthcare will finally converge to mHealth”

Rajendra Pratap Gupta, Leading Healthcare Policy Expert

Prof. K. Ganapathy, President of Telemedicine Society of India and President of Apollo Telemedicine Foundation

Utilizing wireless to access the internet is steadily increasing and telecom operators in India see this as a growth segment. One would not like to call mHealth a killer application, but considering that health is a truly universal requirement, this would perhaps be an apt description. The ubiquitous all-pervading universally available mobile phone can now be used as a tool, and an enabler to deliver healthcare. There are unlimited opportunities and strategies for using the mobile in implementing mHealth in hospitals, insurance companies, Pharma companies, etc. With thousands of health applications, the mobile phone can soon become a hand held hospital.

According to Dr. P S Ramkumar, Director of Applied Cognition Systems, “Practical mHealth will take time, although the concept is easy to sell due to large scale user familiarity with mobile phones. Although mobile communication has equipped the country with approximately 881 million phones, a recent survey has found that, of 30 Tele-Health projects only two had intersect with mobile phones while 60% used free satellite connections provided by government initiatives. The RTBI group of IITM in collaboration with LIRNEasia, Sri Lanka, National Centre for Biological Sciences, Bangalore and Department of Health and Family Welfare, Tamil Nadu, have demonstrated adoption of ordinary text based cell phones by rural health workers showing improvement in disease surveillance and response time. Apollo Telemedicine network foundation has demonstrated Telemedicine application on mobile platforms on 3G networks in collaboration with Ericsson’s Gram-Jyothi program demonstrating Tele-presentation of radiology images, ECG, etc.

Rajendra Pratap Gupta, Leading Healthcare Policy Expert

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Growth of Health Apps by Platform over six month period

PlatformTotal Apps as of 2/2010

New Apps launched: /2010 – 9/2010

Total Apps as of 9/2010

Growth

Apple AppStore Health Apps

4,276 2,860 7,136 66.6%

Google Android Health Apps

505 791 1,296 156.6%

Blackberry App World Health Apps

140 198 338 141.4%

However, the system lacks legal clarity on the question of who is accountable for delayed data, inaccurate transmission and privacy/security loss of the data”

A truly different way of patient empowerment, mHealth can bridge the urban rural health divide. With 50 mobile phones being sold every second, with an urban teledensity of 113% and a rural teledensity of 49%, India should certainly be poised to incorporate mHealth into the very fabric of its healthcare delivery system.

Key stakeholders driving Telemedicine

Tele medicine as a concept has multiple areas of application which are not only based on advantages key to the medical field but also help in the business end by accessing more people and reducing costs for all parties involved. This has led the various possible stakeholders in India to actively implement and promote Telemedicine. A key part of Telemedicine, m-Health or mobile driven health services is receiving the most amount of attention. This is fuelled by India’s unique mobile service cost structure combined with the huge disparate population and low cost of mobile handsets. The major stake holders in the progress of Telemedicine can be broadly classified under three categories :

1. Government and Government Bodies

This includes organizations that facilitate growth of Telemedicine through policy initiatives, and financial backing. It consists of organizations such as the Ministry of Health and Family Affairs, the Department of Information Technology, Ministry of Communication and IT and the various state governments. In India, various departments have been proactive in launching initiatives and partnering with various other organizations to promote Telemedicine.

ŸMinistry of Health and Family Welfare (MoHFW), Government of India

There is a very structured and planned approach toward Telemedicine in India. This is evident from the setup of the National Task Force on Telemedicine under the chairmanship of Secretary, Union Ministry of Health and Family Welfare, incorporating members from various concerned ministries of the union government e.g. Health, Communication & Information Technology and Space; technical agencies e.g. Indian Space Research Organization, Indian Council of Medical Research, Medical Council of India, Centre for Development of Advanced Computing; academic medical institutions and corporate hospitals practicing Telemedicine actively.

ŸState Governments

A large number of state governments have shown positive support for the development and inclusion of telemedical facilities in their state. In Odisha and Uttarakhand, the secondary-level hospitals have now been linked to SGPGIMS at Lucknow for specialty consultation with the support of the governments. ISRO together with the government of Chhattisgarh has established a state-wide network linking the state government medical colleges at Raipur and Bilaspur and other premier hospitals across the country. Similarly, the Rajasthan state government has established a Telemedicine network between six state medical colleges and 32 district hospitals and six mobile vans with ISRO’s aid. The Karnataka State Telemedicine Network Project, run by an autonomous trust formed by the state government, has set up 30 nodes in collaboration with ISRO. The Punjab go vernment has also launched a Telemedicine project, with state-of-the-art facilities at the Government Medical College and Hospital to link the five polyclinics set up in the state. Many state governments, along with the department of IT, have started establishing Telemedicine networks with state specialty hospitals connected with different district and smaller health centres. Some of them are the governments of Tripura, West Bengal, Himachal Pradesh, Punjab, Tamil Nadu and Kerala.

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ŸMinistry of External Affairs Projects

The progress in Telemedicine is not restricted within domestic networking and resource pooling. The ministry of External affairs has initiated a SAARC Telemedicine Network project that connects one or two hospitals in each of the SAARC countries with three to four super-specialty hospitals in India. The super specialty hospitals in India include AIIMS, SGPGIMS, PGIMER at Chandigarh and the CARE Hospital at Hyderabad.

2.Technology Providers

By collaborating with state governments the Department of Information Technology (DIT) and Ministry of Communication and IT (MCIT), has established a Telemedicine network of more than 100 nodes all over India. The medical network includes:

ŸWest Bengal for diagnosis and monitoring of tropical diseases.

ŸKerala and Tamil Nadu Oncology Network for facilitating cancer care.

ŸNorth-eastern and Himachal Pradesh hilly states for specialty health care access.

Another initiative of the ministry, the Pan-African eNetwork Project, along with Telecommunications Consultants India Ltd. (TCIL) is that of setting up a VSAT-based Telemedicine and tele-education infrastructure for African countries in 53 nations of the African Union.

ŸVarious technology providers

This group includes the various companies such as Ericsson, Texas Instruments, CISCO Systems, C-DAC, Sony which provide specialized hardware and software solutions aimed at innovative telemedical services. The category also includes the various stakeholders which provide the sustaining infrastructure and connectivity support. In India some of the players so far have been ISRO, Aircel, Airtel and IBM. The contribution of these stake holders has been in terms of forging relationships that prove to be socio-economically beneficial to the country. With innovation in services and improved efficiencies in communication and support tech, these groups of stakeholders hold the key to the long term growth and commitment to Telemedicine in India.

Ÿ Indian Space Research Organization (ISRO)

ISRO’s pilot Telemedicine project was launched in 2001 with the aim of introducing the Telemedicine facility to the grassroots level population as a part of “proof of concept technology demonstration” program. The Telemedicine facility connects the remote District hospitals/health Centres with super specialty hospitals in cities, through the INSAT Satellites for providing expert consultation to the needy and underserved population.

Telemedicine facilities are established at many remote rural district hospitals in many states and union territories of the country including Jammu & Kashmir, Andaman & Nicobar Islands, Lakshadweep Islands, and North Eastern States, etc. State level Telemedicine networks are established in Karnataka, Kerala, Rajasthan, Maharashtra, Odisha and Chhattisgarh. Many interior districts in Odisha, Madhya Pradesh, Andhra Pradesh, Punjab, West Bengal and Gujarat have the Telemedicine facility.

Presently, ISRO’s Telemedicine Network has enabled 382 Hospitals with the Telemedicine facility. 306 among them are remote/rural/district hospital/health centres and 16 are mobile Telemedicine units, connected to 60 Super Specialty Hospitals located in the major cities. The mobile vans are extensively used for tele-ophthalmology, diabetic screening, mammography, childcare and community health. The Mobile Teleopthalmology facilities provide services to the rural population in ophthalmology care including village level eye camps and vision screening for cataract /glaucoma / diabetic retinopathy. About 150 thousand patients are getting the benefits of Telemedicine every year.



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ŸThe Centre for Development of Advanced Computing (C-DAC)

C-DAC has been working in the area of Health Informatics since early 90s. It has developed several solutions till date in this area. Notably CDAC developed and deployed the first indigenously developed total hospital information system (HIS) software in collaboration with the Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) at Lucknow in 1998.

Currently, there are more than 16 hardware and software Telemedicine activities undertaken by C-DAC.

3. Hospitals and Bio-medical Institutions

The core part of Telemedicine, be it e-health, mHealth or medical research is the medicine. This is driven by the innovation and standards set by the medical fraternity. Innovation in terms of pioneering mobility in medical instrument, spreading awareness of the benefits, reliability and correct use of tele medical techniques are just a few critical roles taken on by organisations under this stake holder category. In India, hospitals and institutes across varied locations and sizes of operation are continuing to be a part of many initiatives. The most notable contributions have been seen from the Apollo Group and SPGIMS. Other significant participants and premier medical institutions include All-India Institute of Medical Sciences (AIIMS), New Delhi (Jammu & Kashmir, Haryana, Odisha, North East states network), PGIMER12, Chandigarh (Punjab and Himachal state network),Sri Ramachandra Medical College and Research Institute (Andaman & Nicobar Islands), Tata Memorial Hospital and Sir Ganga Ram Hospital, New Delhi, The Amrita Institute of Medical Sciences (AIMS), The Asia Heart Foundation, Fortis Hospital, Narayana Hrudayalaya, and Escorts Heart Institute and Research Centre .

ŸThe Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS)

SGPGIMS, since its inception, has been actively involved in promoting Telemedicine. It has helped in networking 14 national and international partner nodes and in carrying out tele-education and tele-healthcare activities. It is also actively involved in various research and development activities in collaboration with its technical partners. The institute is also credited with establishing the School of Telemedicine and Biomedical Informatics to train workers in this upcoming field.

ŸApollo Hospitals

Amongst the latest initiatives, Apollo hospitals is planning to open 1,000 Telemedicine centres in the next three years (2011-14, 1000 days) and is also actively involved in various other eHealth activities, having done over 69,000 tele consultations till date. Apollo Hospitals along with Aircel, has also launched the first Telehealthcare delivery on the mobile for consumers in India. In the past, Ericsson and Apollo had collaborated for a three-month Gramjyoti project, aimed at exploring benefits that can be met for rural India with the advent of internet connectivity and bridging the digital divide. Gramjyoti covered around 18 villages and 15 towns.

In September 2010, Apollo Hospitals joined hands with pan-India telecom operator Aircel, to launch the first telehealthcare delivery on the mobile for consumers in India. With a subscriber base of more than 45 million, Aircel is India’s fifth largest service provider, making it an ideal partner for Apollo to launch a mobile healthcare initiative, initially via two dynamic products – Tele Medicine and Tele Triage.

Role of Telemedicine Society of India in promoting Telemedicine

TSI promotes and encourages development, advancement and research in the science of Telemedicine and its associated fields. It has constantly played a major role in boosting the application of Telemedicine technology in clinical care, education and research in the health sector. TSI fosters networking and collaboration among interest groups in Telemedicine technology and professionals from different streams of science, health care providers, policy makers, NGOs and industry.



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It promotes training of students, health professional, research fellows and technicians, in various aspects of Telemedicine. TSI coordinates with academic institutions and Medical Council of India, AICTE, DOECC and regulating agencies in developing curriculum for Telemedicine training courses and incorporates appropriate modules in the Medical, Dental and Paramedical training programs. TSI has been arranging regular scientific meetings, symposia, seminars and workshops for Telemedicine. It is heading the development of appropriate clinical and industry policies and standards. TSI spreads knowledge in Telemedicine field by publishing brochures, periodicals, journals and has also created an exclusive web site for the society and regularly updates it with Telemedicine news. TSI works in close collaboration with scientific organizations and the industry in development and implementation of innovative products & services related to Telehealth. TSI also organizes trade exhibitions during annual meetings of the society.

Public Private Partnership (PPP)

An example of a Telemedicine public-private partnership is the collaboration of Narayana Hrudayalaya with the government and ISRO at Chamarajanagar District Hospital (Govt. owned), which is 185 km away from the super specialty cardiac care hospital situated in Bangalore, Karnataka. The network helps provide remote cardiac care to the local population of Chamarajanagar. According to Dr. Devi Prasad Shetty, Chairman, Narayana Hrudayalaya, the unit has treated about 52,000 patients since its inception in 2002.

An impact study by an independent evaluating agency on 1,000 patients at the district hospital has reported that the patients who availed Telemedicine consultations spent only 19% of the cost they would have spent if there was a need for them to travel to the nearest city for similar treatment.

The Tripura Vision Centre Project is a novel and innovative project in delivering preventive and primary eye care services to remote and underserved areas of Tripura, in North East India. Established in April 2007, the project was designed by IL&FS-ETS, a social infrastructure initiative, in collaboration with Aravind Eye care system, for the State Department of Health. Services are rendered through 40 vision care systems (VC), staffed with trained paramedical ophthalmic assistants. Situated in the premises of Community Information Centre (CICs), the VC can leverage the Tripura State Wide Area Network (TSWAN) and existing infrastructure to connect to the base hospital, IndiraGandhi Memorial (IGM) Hospital, situated in the state capital of Agartala. Here, outpatient department ophthalmologists provide remote consultations through video conferencing and application modules. Preliminary treatment options like prescriptions and spectacles are provided online. Only those requiring special care like surgeries or complicated interventions are required to visit the hospital, thus keeping a check on the logistics and expenditure.

Since its inception, the project has now expanded to 35 centres, having screened 71,000 patients till August 2010, among whom approximately 5,000 were referred to the base hospital. It has been estimated that each VC screens around 100 patients per month, thereby having a large impact on the healthcare delivery. The project was recognized by the Government of India and received the National e-Governance Award in 2009.



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According to Sri Sachin Pilot, Minister of State for Information Technology, Government of India, a change in mind-set needs to be there for Telemedicine to grow in India. He stressed that both urban and rural India should start accepting Telemedicine with open heart as most of the people still prefer physical sessions with doctors rather than telehealth sessions. It is very difficult for the government to reach all the 6,48,000 villages across India, and Telemedicine is required to play a big role here.

He also emphasised on the importance of partnerships between government, private sector, NGOs and other organisations. According to him, Government can play the role of a facilitator, where an ecosystem can be created. He stated that framework should be such that it avoids duplication of models and research and will further help to save time and money.

The Indian Ministry of Health and Family Welfare, Ministry of Communication and Information Technology as well as certain state governments and ISRO, are playing a significant role in the development of Telemedicine in India. Below are a few examples of initiatives by the Ministries and State Governments and also initiatives by other government bodies in India:

e-Network Project

Ÿ Government of India, in a joint initiative with the African Union, launched the Pan-African e-network project, which supported tele-education, telemedicine, e-commerce, e-governance, infotainment, resource-mapping and meteorological services.

Ÿ The project showcases India’s proficiency and core competence in the ICT sector. It was aptly described as a ‘shining example of South-South cooperation’ by the Minister of External Affairs, Shri Pranab Mukherjee, at the inauguration of the project on February 26, 2009.

Ÿ Telemedicine is a major part of the project. It connects the nodal centres in India with the 53 nations of Africa through the use of electronic information and technology (ICT) to provide Telemedicine to its African counterparts.

Ÿ India provides seamless and integrated satellite, fibre optics and wireless network

infrastructure. About 12 Super Speciality Hospitals from India provided expert services

t h ro u g h a n e t w o r k c o n n e c t i n g 5 3 re m o te h o s p i ta l s a n d 5 r e g i o n a l

hospitals spread all over Africa. The entire network will cover 53 Member States in African

Union and provides VSAT based star network with 116 + 53 VSAT terminals, equally distributed

overall the Members States and a Hub located in one of the African Union Member States.

Ÿ A pilot project was launched in Ethiopia in mid-2007, connecting educational and medical

centres of excellence in India & Ethiopia and it was a success.

Multiple Projects Undertaken by Ministry of Health

and Family Welfare

Ministry of Health and Family Welfare has taken several initiatives to improve the healthcare services in

India. Sri Dinesh Trivedi, Minister of State for Health and Family Welfare in India has undertaken four

projects.

Ÿ Setting up I-Hind: I-Hind (Initiate Indian Health Information Network Development) is a web

based network aiming to connect all healthcare establishments in both public and private sector.

Ÿ National Health Portal: There is a need to create awareness about healthcare among masses and

hence Ministry of Health and Family Welfare is creating national portal on health. It is the first

national portal which guides people on health issues, places to go for treatment and other

information vital for them.

Ÿ Emergency Medical Services: Ministry is working on providing 24/7 emergency medical services

Ÿ Health Literacy Programme: Ministry is also working on a healthcare education or literacy

programme for healthcare service providers in rural areas. It includes skill development

programme for healthcare workers such as ASHA workers, Community workers and support staff

at PHC’s (Primary Health Centres).

Apart from these initiatives, Ministry of Health and Family Welfare is also implementing a network

called the “Integrated Diseases Surveillance Programme”. This network connects all district hospitals

with medical college hospitals of a state to facilitate tele-consultation, tele-education, training of

health professionals and monitoring disease trends. A few state governments have shown initiative to

include private doctors and medical colleges and are providing them funds and equipment for

implementing the programme.

Similarly, the National Cancer Network has been implemented to connect 25 regional cancer centres

with peripheral hospitals to facilitate the national cancer control programme.

Some of the other important mHealth initiatives includes Tele-ophthalmology project, National

Telemedicine Grid, National Onconet Project, National Medical College Network and National Digital

Medical Library Consortium.

Mr. Dinesh Trivedi, former Union Minister of State for Health, had proposed the idea of providing

electronic health card to every child in the country. This will be provided as a birth certificate to capture

an individual’s health record from the time of birth.

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Establishment of a Telemedicine Network

Rajasthan State Government, in collaboration with ISRO, has established a Telemedicine network. The

network was launched in February, 2006 and it connects 6 state medical colleges, 32 district hospitals

and the SMS hospital in Jaipur and also has six mobile vans equipped with the mHealth equipment.

ISRO provided satellite services to the State Government free of cost during the first five years of the

project.

The Karnataka State Telemedicine Network Project

Karnataka State Government formed an autonomous trust to run a Telemedicine project called ‘The

Karnataka State Telemedicine Network Project’. The state has set up close to thirty nodes in

collaboration with ISRO. The Telemedicine network in Karnataka consists of all the district hospitals in

the state connected to five specialty hospitals in Bangalore and Mysore.

Odisha Telemedicine Network

Ÿ In Odisha, Telemedicine activities were initiated in 2001 with support fr om

Department of Information Technology, Government of India and Sanjay Gandhi Post

Graduate Institute of Medical Sciences (SGPGIMS), Lucknow. Subsequently, in the same year,

ISRO/Dept. of Space, Government of India, came forward with an offer to establish a

Telemedicine Network in the state of Odisha.

Ÿ Phase I of Odisha Telemedicine Network was established in 2003 that connected all the three

Govt. Medical college of Odisha (Located in three districts of Ganjam, Sambalpur and Cuttack),

to Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, through

Satellite-based VSAT connectivity. The hardware and software were provided by ISRO, along

with bandwidth, free of charge.

Ÿ In 2007, with similar support from ISRO, the network expanded further to include district

headquarters, hospitals of Koraput, Bhawanipatna, Baripada, Rayagada, Sundergarh, and

Capital Hospital, Bhubaneswar, as phase II implementation of Odisha Telemedicine Network.

Ÿ In the third phase, implemented in the year 2010, all the rest 21 District Headquarter Hospitals

of Odisha and one more hospital, which is Rourkela Govt. Hospital, Rourkela were provided

with Telemedicine facility and were connected to all the three Govt. Medical College Hospitals

of the state zone-wise.

State-wide Telemedicine Network in Chhattisgarh

Chhattisgarh State Government, with the support of ISRO, has established a state-wide network,

linking state public medical colleges to each other and further to premier hospitals across the country

like All India Institutes of Medical Sciences (AIIMS), New Delhi and Fortis Hospital, Noida.

OncoNET India

Ministry of Health and Family Welfare has undertaken the following initiatives for building

infrastructure for Telemedicine in India:



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Under the National Cancer Control Program, it established OncoNET India, a network connecting 25 Regional Cancer Centres and 100 peripheral centres, to provide comprehensive cancer treatment facilities and carry out cancer prevention and research activities.

Draft proposal for National Telemedicine Grid has also been prepared by ISRO and submitted to the Ministry. Apart from this, certain Telemedicine programs are also being supported by some super specialty hospitals at central government, corporate sectors and state government level.

Aarogyasri

Community Health Centers by some state governments are helping build mHealth infrastructure at grassroots level. ‘Aarogyasri’, an initiative by Andhra Pradesh government, is one such example. It is revolutionizing public health through conviction and innovative ICT application. Aarogyasri runs a 24×7 operational call centre manned by doctors and paramedics, and telephonic medical counseling is provided through toll free numbers—104 and 108.

A few of the other state governments like Karnataka, Tamil Nadu, Rajasthan, Gujarat, and Madhya Pradesh have been running a number of mHealth projects in the recent past with successful outcomes.

DIT established more than 75 nodes

Department of Information Technology (DIT) and Ministry of Communication & IT have established more than 75 nodes all over India. DIT has supported the following Research and Development initiatives :

Ÿ Development of Telemedicine software systems by C-DAC and validation for three premiermedical institutions.

ŸWide Area Network (WAN) for diagnosis and monitoring of tropical diseases in West Bengal, developed by Webel (Kolkata), Indian Institute of Technology, Kharagpur and School of Tropical Medicine.

ŸUndertook initiative, in a project mode, for defining "The framework for Information Technology Infrastructure for Health (ITIH)", to efficiently address information needs of different stakeholders in the healthcare sector.

ŸKerala Oncology Network for providing services for cancer detection, treatment, pain relief, patient follow-up and continuity of care in peripheral hospitals of Regional Cancer Centre (RCC), Thiruvananthapuram.

Many medical institutions, both private and public, have contributed to development of required infrastructure for Telemedicine and mHealth in India. Sanjay Gandhi Postgraduate Institute of Medical Sciences, a premier institution in public sector, started its Telemedicine activities way back in 1999. Other institutions such as All India Institute of Medical Sciences (AIIMS), New Delhi (Jammu & Kashmir, Haryana, Odisha, North East states network) and PGIMER, Chandigarh (Punjab and Himachal state network) and Sri Ramachandra Medical College and Research Institute (Andaman & Nicobar Islands), have done similar activities. According to Shri Jayanth Banthia, Additional Chief Secretary, Public Health Government of Maharashtra, “Due to the ever increasing shortage of doctors and practitioners, government should focus on Telemedicine”. He admitted that right now Telemedicine is lagging behind and in this context discussed about the pilot project in Maharashtra which focussed on connecting medical colleges, but was not able to extend to the private sector, except for Nanavati Hospital. He proposed a partnership to those who are willing to work in Maharashtra and said that government will realign budget in this area and will look to double the amount allocated currently.

Initiatives by Hospital and Medical Institutions



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Telemedicine Service by Narayana Hrudayalaya

Narayana Hrudayalaya started its Telemedicine service in the year 2002 to cater mainly to the rural populace in the country. The Telemedicine network of the hospital connects to countries like Malaysia, Mauritius and Pakistan; with most of the cases referred through Telemedicine being cardiac ones. ECG reports, Audio/Visual data, CT scans, X-rays and MRIs, and their analysis, are exchanged via the telephone line, broadband connection or satellite. The hospital uses a Telemedicine ECG machine manufactured by Schiller India, a Germany-based company. The Telemedicine services provided by the hospital are free and more than 21,000 cases have been referred using this service. Narayana Hrudayalaya is also a part of "The Karnataka Telemedine Project" which was inaugurated on April 8, 2002 and links two rural hospitals in Saragur, Karnataka viz. the Chamarajnagar District Hospital and the Vivekananda Memorial Hospital with the Narayana Hrudayalaya.

Apollo Telemedicine Networking Foundation

Apollo’s vision is to provide a successful working model of Telemedicine which self-propagates throughout India and into the global developing world. It will provide a channel for continuous access to the most sophisticated medical support systems at all times. Further, Telemedicine shall improve patient care, enhance medical training, standardize clinical practice, stabilize costs and unite clinicians worldwide. The Apollo Telemedicine Network allows the participant sites to collaborate with institutions in the country and abroad and provides patients with access to better healthcare in areas not adequately served by the medical community.

The President of the United States of America, President Bill Clinton, on his visit to India in April 2000, visited an Apollo-Telemedicine station in Hyderabad and said, "I think it is a wonderful contribution to the healthcare of the people who live in rural villages and I hope that people all over the world will follow your lead, because if they do then the benefits of the development in medicine can reach everyone and not just to people who live in big cities." Regarding mHealth initiatives, Professor K. Ganapathy, President and Head, Apollo Telemedicine Networking Foundation said, “My interest in mHealth commenced in Aug 2007 when Ericsson approached me to understand the feasibility of providing value added health services using 3G along with other services to a cluster of villages near Mahabalipuram. We carried out the first clinical trial using a 3G spectrum specially obtained for the study. Clinical evaluation of 240 patients through videoconferencing, including tele-auscultation and transmission of 12 lead ECGs entirely through wireless were carried out, followed by a mini master health check-up for 75 patients in a village. X-rays and ultrasound images, including video streaming of Echocardiograms were transmitted through wireless. Following this, SMS texting was used to provide appointment alerts, inform doctors about admissions, lab results, etc. Home grown mobile phone software was then deployed in management of diabetes. In pilot projects, HbAC1 values were significantly lowered. Recently, we have initiated electronic house visits and have even provided healthcare on moving trains through existing wireless networks. To demonstrate commitment to mHealth, 24/7 Medical Response Centres have been recently started by a sister concern Health Net Global. Accessible to mobile phone users, these cost effective resource centres, are manned by trained personnel, who use customized evaluated algorithms/triage protocols to evaluate the caller’s health needs. The protocol has been tested with millions of patient encounters in the UK during the last decade. All this can be availed at a cost of less than INR 40 for an initial teleconsult.”

CARE Launched Telemedicine at District Hospital

CARE plans to make healthcare accessible by using latest communication technology for connecting population living in villages, towns, and small cities with the hospitals in the big cities. The initiative will enable the rural population across the country to seek medical advice from experts sitting in large super specialty hospitals without having to bear the financial burden and stress of commuting to the cities.

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In the first phase, CARE launched Telemedicine at the district hospital in Mahaboobnagar, which enables transfer of textual data, images and video conferencing between the district hospital and CARE Banjara Hospital on a continuous basis, thereby enabling patients to get the best of the opinions from their local site.

Nanavati Hospital provide Teleconsultations and CME to African countriesNanavati Hospital is the only hospital in Western India to be recognized by Ministry of External Affairs through TCIL to provide super-specialty services for Pan-African e-Network, and since March 2009 is also one amongst the eleven prestigious hospitals in India like AIIMS, Delhi / Amrita Institute, Kochi / Narayan Hrudayalaya, Bangaluru, etc. to provide teleconsultations and CME to African countries.

A special studio has been created in the Telemedicine centre where professional gadgets like Sony C-Mos, DVCAMcorder, large Electronic poly-vision touch screen board, Sony Anycast editing station, Canon Visualizer, 42” plasma monitor by Hitachi, servers from HCL are housed. Connectivity network used is based on the undersea fiber optic cable by Airtel.

Telemedicine Master centre is now connected to 28 District hospitals in Maharashtra under National Rural Health Mission (NRHM) project. Nanavati hospital is the only private hospital recognized by Maharashtra state NRHM for super-specialty services. As NRHM services will expand further, Nanavati would be catering to 20 more sub-district hospitals in Maharashtra. This tie up has resulted in benefitting many patients by getting teleconsultation from the specialists since 2008. Furthermore, during the swine flu epidemic, specialists actively participated in the CME programs conducted by different district hospitals.

SGRH Launched Telemedicine CentresSir Ganga Ram Hospital (SGRH) launched its Telemedicine centres in 2007. The centres are in Gohana in Haryana, Kaithun in Rajasthan and Dasmal in Himachal Pradesh. All the three nodal centres have the medical kiosks with the facilities of X-Ray unit, ECG unit, laboratory and Telemedicine unit and are linked to SGRH by video conferencing technology.

AIMS Servicing Remote Islands through TelemedicineAmrita Institute of Medical Science (AIMS) has been providing compassionate care through Telemedicine since 2003, servicing remote islands such as Lakshadweep and Andaman & Nicobar, as well as Leh-Ladakh in Kashmir. Now, more than 32 centres in India are connected to AIMS. The Institute has also used the technology to provide specialty medical support during times of natural disasters, including the 2004 Indian Ocean tsunami and 2008 Bihar floods. Aside from providing consultations to the remote corners of India, AIMS uses its Telemedicine link to educate doctors in remote primary centres in the latest medical advancement through seminars, workshops and teaching programs. Amrita’s Telemedicine program is made possible through its link with an ISRO satellite.

Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP)Narayana Nethralaya Postgraduate Institute’s flagship Teleophthalmology Program initiated the ‘Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity’ (KIDROP) in 2008, to provide Retinopathy of Prematurity screening for rural and semi-urban infants in hitherto unscreened centres using the backbone of Teleophthalmology and Wide-Field-Digital Imaging devices.

The pilot project initiated in 2008 started with 5 centres. In the first quarter of 2011, KIDROP has grown to screen in 25 centres spread across the southern 6 districts of Karnataka in Southern India. Most of these are in the rural or semi-urban centres. None of them had ROP screening prior to being included. Since 2010, the project has partnered with the Min. of Health and Family Welfare to include 36 more centres, which will be operational by 2012.

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Narayana Nethralaya has non-commercial collaborations with i2i Telesolutions, Bangalore, who have developed an internet based hardware-software platform using a patented compression technology that allows live uploading, viewing and reporting of images from any part of the globe directly accessed by the KIDROP doctors on their PCs and smart phones. This technology was adjudged among the "Top Ten Medical Innovations" in 2009.

In 36 months of initiation using India’s first portable Retcam Shuttle since March 2008, KIDROP screened over 3400 unique infants in over 25 neonatal care centres spread over 6 districts covering a radius of care of over 350 km. Over 400 infants received laser and other treatments in the peripheral centre without having to travel to the city, among whom, over 72% received treatment which were either free or subsidized, and over 18,000 imaging sessions were recorded and an image database of over 200,000 images were generated.

ISRO Telemedicine Network

The ISRO initiative is aimed at :

ŸProviding Telemedicine technology and connectivity between remote/rural hospitals and super specialty Hospitals for teleconsultation, treatment and training of doctors and paramedics.

ŸProviding the technology and connectivity for Continuing Medical Education (CME) between medical colleges and post graduate medical institutions/hospitals.

ŸProviding technology and connectivity to mobile Telemedicine units for rural health camps especially in the areas of ophthalmology and community health.

ISRO is playing a catalytic role by providing proven technology for introducing SatCom based Telemedicine in the remote parts of our country through pilot projects. In its project, Government run hospitals and a few trust/NGO-run hospitals are selected for training so that they get sufficient experience to run the facility and the users themselves can subsequently introduce Telemedicine in an operational mode at national level. Presently ISRO Telemedicine network covers 382 Hospitals – 306 remote/rural/district hospital/health centre and 16 mobile Telemedicine units connected to 51 super speciality hospitals located in the major cities. They include hospitals in Jammu and Kashmir, Lakshadweep and North Eastern states. Also included in the network are mobile telehospitals that visit various villages in Madurai and Theni districts of Tamil Nadu, mobile teleophthalmology units for the eye care rural camps, and Onco-net project for cancer care. A temporary Telemedicine facility for 2 months is set up at Pamba at the foothills of Sabarimala shrine for the benefit of visiting pilgrims during December every year.

More than 100,000 patients have benefitted with Teleconsultation and treatment using ISRO Telemedicine network. Patients have saved approximately 81% of cost, mainly because of the savings in travel, stay and treatment at the hospitals in the cities. In the case of off-shore islands, the cost saving is enormous, both to the government and the patients.

SAARC Telemedicine Network

The South Asian Association of Regional Cooperation (SAARC), created as an expression of the region’s collective decision to evolve a regional cooperative framework, received a major thrust during the 14th SAARC Summit held in New Delhi in April 2007. The project aimed to connect one/two hospitals in each of the SAARC countries with three to four super specialty hospitals in India. The super speciality hospitals in India include the AIIMS, New Delhi, SGPGIMS, Lucknow, PGIMER, Chandigarh and the CARE Hospital, Hyderabad. Some of the hospitals outside India are JDWNRH, Bhutan, Indira Gandhi Child Hospital, Kabul, Afghanistan & Patan Hospital, Kathmandu, Nepal.

Initiatives by National and International Organizations



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The SAARC Telemedicine network is being dev eloped as an exemplary model for implementing

projects at the regional level. It has immense potential to expand the scope of regional cooperation to

other ICT enabled areas such as education, business process outsourcing and mass communication.

Cisco Health Presence 2.0 Solution

Cisco has conceptualized and created Cisco Health Presence 2.0 Solution, which is a Telehealth solution

designed to improve access to healthcare, enhance collaboration among doctors, and promote

participative healthcare. The solution can be accessed from a variety of video end points supported by

Cisco including Tele-presence, Tablet PCs, and desktops. The provider (doctor) can be mobile and still

be able to consult a patient located remotely by using a portable video end point device such as Tablet

PC. The care provider is not limited to a fixed Telemedicine pod, as he does not need to come to the pod

to offer teleconsultation. The care provider can be in his clinic, hospital, or at home. This improves

convenience, enhances reach, and maximizes the productivity of care providers. The Cisco Nurse

Connect solution, facilitates collaboration among mobile care givers, enabling them to reach each

other and to be reached over multiple types of devices, wherever they have a wireless signal. This

provides more efficient patient care from almost any location. The integrated Cisco Nurse Connect

voice and data solution delivers nurse call alerts to Cisco wireless phones and other end points.

Joint Initiative by Cisco and Apollo

Cisco is moving along in its multi-pronged initiative to connect the far-flung populations of India with

services and resources through technology. Cisco and Apollo Hospitals plans to accelerate access to

healthcare with the Cisco Health Presence Extended Reach technology. As a first step, the Apollo

Hospitals Group and the Apollo Telemedicine Foundation deployed hundreds of the Extended Reach

solution across Apollo remote clinics and hospitals, enabling patient access to any doctor across the

Apollo system.

"We are looking beyond India for deploying this technology. Doctor--anyone, anytime, anywhere will

be our slogan," said K. Ganapathy, President and Head of Apollo Telemedicine Networking Foundation.

According to Sangita Reddy, Executive Director of Apollo Hospitals Group, “At Apollo Hospitals, we

constantly endeavour to introduce new models to help make quality healthcare accessible to the

masses. The alliance with Cisco will revolutionize the delivery of healthcare in India”.

Cisco Health Presence Extended Reach technology represents significant advances in technology and

telecommunication techniques, effectively delivering healthcare 24x7 remotely. As part of this

initiative, Cisco and Apollo have collaborated in Raichur (Karnataka, South India) to demonstrate how

healthcare in rural areas can be transformed. With the technology, doctors do not need to visit a

Telemedicine room to connect with patients. They can now consult with patients from a laptop

supported by an Internet connection. A detailed 'clinical examination' and review of all investigations is

now possible with the option of recording the entire interaction.

Bluetooth Enabled Monitors with eHealth Points

Sensaris is piloting Bluetooth enabled pulse oxymeters, glucometers, thermometers and blood

pressure monitors with eHealth Points in India. New features, based on user feedback, are added to

software running on Android phones. The company is also providing the equipment and infrastructure

for several programs regarding emergency medicine (mountain rescue teams), chronic disease

screening and home based healthcare.

Initiatives by Private Technology Players



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Sero’s mHealth Solution

Health India (which provides primary care services in India) and Sero solutions are working together to

deploy Sero’s innovative mHealth solution which enables medication compliance using Sero’s unique

mHealth technology which uses Near Field Communication, a wireless technology that is being built

into a new generation of smart-phone handsets by vendors such as Blackberry. It enables transactions

to be completed by simply touching the phone against other electronic devices.

Satnam S. Bains, Managing Director of Sero Solutions said, “We are embarking on a truly innovative

model for mHealth in India, as the innovation exists at several levels in the engagement process. This

includes technical innovation coupled with clinical innovation. We are embarking on this project

through collaboration between RIM (Blackberry) and Health India”.

Health India’s vision is to dramatically reduce ill health events for all, with special emphasis on the

aspiring urban communities, via a high impact Primary Health solution and to set up an effective

scalable health business, delivering high quality, low cost primary healthcare; working with partners

and training institutions to establish a workforce of general practitioners, nurses and healthcare

assistants cascading to tier 2, 3, 4 level cities, thus enabling outreach to the surrounding poorly served

rural and semi- urban communities. This will be done through a hub and spoke model of satellite

healthcare units supported by primary healthcare centres located within easy travelling distance.

The NFC eHealth solution from Sero allows a doctor or patient to monitor medication compliance and

apply governance to a medication regime through a combination of deploying a smart medication card

and a smart mobile phone. Patients’ medication schedules are recorded on a central system. The

central system contains the names of the medications and the times at which these medications should

be taken. The patient is issued a Smart medication card. The cards contain a number of buttons which

correspond to a patient’s medication schedule. Once a medication has been taken, the button on the

adaptor responding to the medication is pressed by the patient. This records the fact that they have

taken their medication.

After this, a NFC mobile device is touched against the card to record that the medication has been taken,

by sending the information across a cellular network onto the central system in a cloud infrastructure.

The card can also be used for governance purposes, e.g. each doctor can immediately see what

medications a patient is on, as the patient can present the card to the GP whenever they have a

consultation. Therefore they can gain an awareness of what other medications the patient is on, to

avoid interactions. The solution also has the option of setting up a timed medication schedule for the

patient. In this situation, a patient can receive a SMS text to take a specific medication as a reminder.

Freedom HIV/AIDS Initiative for Mobile Users

ZMQ Software Systems, India, in the year 2005 started a social initiative by the name Freedom HIV/AIDS.

The initiative is supported by Delhi State AIDS Control Society.

Freedom HIV/AIDS comprises mobile games targeting different mind-sets and psychology of mobile

users. The games are deployed on low-end black/white to sophisticated high-end coloured devices.

Games are free for download through the corporate social responsibility program of ZMQ.



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PaDiSys mPRO and PaDiSys mTA

Now, Pos M-Solutions (a mHealth Technology Solutions and Services Company), with office in US and an offshore development centre at Hyderabad, India, launched mobile based Patient Reported Outcome capturing solution - PaDiSys mPRO and mobile based Trial Adherence System - PaDiSys mTA in, 2010.

The two highly intuitive solutions, PaDiSys mPRO and PaDiSys mTA allows sponsors, CROs and research institutes to capture patient information on a real time basis, while complying with international guidelines like that of CFR 21 Part 11, FDA, EMEA, etc.

Asara, Vallabhi Telehealth Centre, 104 Advice, and 104 Sarathi Programs by HMRI

HMRI is a not-for-profit organization based in Hyderabad, Andhra Pradesh and supported by the Piramal Group. The organization is committed to addressing the availability, accessibility and affordability issues of healthcare services to underserved communities. HMRI endeavours to strengthen existing public health systems and leverage ICT tools, along with modern management expertise, to significantly augment healthcare delivery by providing access to low-cost physical and virtual healthcare services to the public with a focus on the rural and remote population. HMRI’s vision is to strive for equity in healthcare, excel in its endeavour to be knowledge driven and realize the mission of “health for all”.

HMRI runs two Telemedicine projects. In partnership with The MacArthur Foundation, US, HMRI operates Asara in Araku Valley, Andhra Pradesh. Asara was launched in August 2010 and provides antenatal and postnatal care to 140 tribal habitations.

In partnership with Aitharaju Foundation, HMRI launched Vallabhi Tele-Health Centre in August 2009. Medical specialties supported by Vallabhi Tele-Health Centre include general physician, obstetrician and gynecologist, pediatrician, ear, nose, and throat specialist, dentist, dermatologist.

HMRI launched a Health Information Helpline program in Andhra Pradesh and Assam to provide free health information round-the-clock to the citizens of Andhra Pradesh through ‘104 Advice’ and in Assam through ‘104 Sarathi’. 104 Advice was launched in February 2007 in Andhra Pradesh and has grown from a four-seat call centre that responded to 200 calls per day, to a robust, complex operation with around 400 seats that respond to 40,000 calls per day. 104 Sarathi was launched in November 2010 and currently responds to 3,000 calls per day. These kinds of programs have been very successful in countries like the UK in the past.

SkyHealth Rural Centres by World Health Partners

World Health Partners (WHP), is a not-for-profit franchising organization that provides healthcare services through its SkyHealth Rural Centres, to low socioeconomic groups, especially those living below the poverty line, in Uttar Pradesh, India.

Uttar Pradesh Pilot Program aims to cater to an estimated 4 million people living in the project area of Meerut, Muzaffarnagar and Bijnore districts, 3 million of which reside in rural and remote villages. To reach such a large population, WHP established a network of local and regional providers, with a central base of operations in New Delhi. Using state-of-the-art satellite, broadband and computer technologies, the project links connected city-based doctors with patients living in remote settings. Contracted local partners manage training, technological support, delivery of medicines and supplies

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to all providers in the WHP network. The health services provided by the WHP network include comprehensive preventive and curative care, as well as reproductive health and family planning services. Family planning is provided on an on-going basis at the shops, Telemedicine centres and franchisee clinics. These providers also help WHP organize annual transit clinics, bringing services close to the clients. Because these transit clinics qualify for special government grants, WHP is able to deliver care to the poorest communities in close collaboration with the public sector. The challenge before WHP is not only creating access to services for the poor, but also ensuring that these services are affordable and of good quality. The project will create access by training and employing suitable people in the community. It will integrate family planning into the providers’ existing suite of health services, thus making family planning viable. The project will use India’s well-established market-distribution system to make non-clinical family planning methods, clinical supplies, and therapeutic medicines available for purchase at, or close to, the village.

Teledoc by Jiva

Jiva Institute, an India-based non-profit with the support of Soros Foundation, launched a project by the name Teledoc in 2003. Teledoc provides handheld mobile phone devices to village health workers in India, permitting them to communicate with doctors who use a web application, to help diagnose and prescribe for patients. Teledoc has treated more than 10,000 patients online and over 12,000 patients at 120 free health camps in India, delivering a total blended value of over $230 million for 66,000 patients. Teledoc won the World Summit Award for eHealth, presented on 10 December 2003 at the World Summit on the Information Society (WSIS) in Geneva, Switzerland.

Integrated Telecardiology and Telehealth Project

Asia Heart Foundation, installed in 2002 by Narayana Hrudayalaya, Bangalore, Karnataka, achieved a figure of more than 2000 tele cardiology consultations through an enterprise based network.

The Telemedicine venture of Asia Heart Foundation is called the ‘Integrated Telecardiology and Telehealth Project,’ which is primarily aimed at providing cardiac care to economically impoverished citizens. Cardiac Care Units (CCUs) have been set up in the project areas to host comprehensive cardiac care as well as other medical facilities. The entire project operates as a hub-and-spoke network so that the main CCUs are connected to the local CCUs using Very Small Aperture Terminals (VSATs) that are connected to satellites. In this way, a patient located in one of the remote CCUs can have a videoconference-enabled consultation with a specialist located in the main centre. For other kinds of data-transmission, ISDN connectivity is also available. Currently, about 12 centres are operational in Karnataka, West Bengal and Tripura, with the main CCUs in Bangalore and Calcutta.

Nepal

Telemedicine has been more or less remained confined to the developed nations but if utilised properly, it holds greater potential for developing nations as health needs of a majority of population remains unmet. Nepal has a dismal 0.8 health centres per 100,000 of the population and is looking at Telemedicine to provide access to majority of its population.

Kathmandu Model Hospital’s pilot project

Launched in 2006 by Kathmandu Model Hospital with the support of NREN, this pilot project connects more than 80 km away rural community hospital through a wireless network. The project has been very successful and has been replicated in many rural areas of Nepal. It has now established 10 rural health centres which have been conducting regular virtual classes and real time teleconsults. The project has progressively broadened its horizons by having connectivity with leading universities of countries like USA, Australia and Japan, among others.

Telemedicine Initiatives in Neighbouring Countries



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OM Telemedicine Centre

OM Telemedicine Centre was the first Telemedicine centre in Nepal, established in the year 2004.

It has one set of Telemedicine equipment which includes; one television, one web camera, one microphone, one set of desktop computer and printer/scanner, an Integrated Service Digital Network (ISDN) modem, and a media converter for broadband internet connection. It has a staff of 4-7 persons. It has also collaborated with Apollo Hospitals, India, for Telemedicine linkages. The collaboration is mainly used for follow up treatment. Patients who have received treatment at Apollo Hospitals and cannot afford to travel back to India, can consult with doctors through Telemedicine.

Pakistan

The doctor to population ratio is 1: 1,436 in the country compared to the 1: 500 in wealthy countries. Being one of the densely populated nations in the world and having poor healthcare services, Telemedicine can provide a solution for improving public health in Pakistan.

Telemedicine started in 2000 in Pakistan, mostly as an initiative by NGOs in collaboration with local hospitals. Government began to chip in only in 2005 with funds and technology support.

PAKSAT HealthNet Project

The project aims to offer the following services at the Telemedicine centre:

ŸTele-diagnosis/consultations: Specialists in hub hospitals examine patients remotely and provide diagnosis and consultations

ŸTele-treatment: Patients diagnosed with a disease, or their doctor, seek specialist advice on treatment to be offered

ŸENT, skin, chest, cardiology, and psychiatry specialities

The rural areas that will be covered under this project include :

ŸPUNJAB1 (Holy Family) : Attock, Khushab, D.G Khan & Pindi-Gheb

ŸPUNJAB2 (Mayo): Gujarat, Sahiwal, Rajanpur, Jhang

ŸSIND (JPMC): Shikarpur, Mirpurkhas, Ghambat, Jacobabad

Ÿ The entire project coverage area will be divided into hubs and each hub has to be connected with 4 rural hospitals.

The equipment used will include a Desk-top Video conferencing set-up, a VPN based broadband data network for electronic transfer of video, voice, imaging and text data between remotes, 1 X Digital stethoscope, 1 X Digital ECG, 1 X Digital dermascope/ autoscope, 1 X Digital camera and the hub.

The project is a part of US Government’s Digital Freedom Initiative which aims to promote use of technology in developing nations.

Public -Private Telemedicine Partnership with US

ŸThe project will have both pre-operative planning and follow up facilities.

ŸCardiac assessment, ophthalmology, dermatology, radiology, infectious disease and peri-natal evaluations, and medical triage for traumas and acute illnesses, are the diseases for which treatment will be available.



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ŸProject partners include IBM, Wateen Telecom, Motorola Inc., and Medweb Inc.

Bangladesh

The physician to population ratio is 1:5,000 in the country compared to 1:500 in wealthy countries. Hospital bed to population ratio is also very high at 1:3,750.

BIID’s e-clinic Online Healthcare Initiative

Bangladesh Institute of ICT Development (BIID’s) e-clinic online healthcare initiative was launched on October1, 2010. Services offered under this program include; medical consultation, maternal health information, post natal health care, child health care, adolescence health care, and (e-hl) project.

15 month Program by European Commission

ŸThe program was started in January 2003

ŸFunded by the European Commission under the Asia IT&C program

ŸThe project built two network segments using point-to-point radio link with a bi-directional bandwidth of 2 Mbps

ŸThe first set up covered an air distance of around 8km

ŸThe second network created a length of 134km

Sustainable Development Networking Programme

ŸTelemedicine sessions by Sustainable Development Networking Program (SDNP) was started in August, 2005

ŸThree sessions were held under the project

ŸTwo sessions were held, one in between Cox's Bazar and Dhaka and another between Satkhira and Dhaka head office.

ŸThese sessions included real patients at a remote site with one physician and one medical expert present at the head office to provide suggestions acting as third opinion.



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Opportunities

Specialty health infrastructure is the need of the hour and Telemedicine presents an opportunity for telecom vendors, healthcare providers and policy makers to provide healthcare to masses. India, with its diverse landmass and huge population is an ideal setting for Telemedicine. Telemedicine is currently receiving a huge push from the Indian Government to address the healthcare inadequacy in India. There are various government, quasi-governments and private Telemedicine solution providers and a few societies and associations actively engaged to create awareness about Telemedicine within the country.

Continua Health Alliance

With its large medical and IT manpower and expertise in these areas, India holds great promise and is emerging as a leader in the field of Telemedicine. It offers following opportunities

Increased Accessibility

India is characterized by low penetration of healthcare services wherein 90% of secondary and tertiary healthcare facilities are in cities and towns. Primary health care facilities for rural population are highly inadequate. Despite several initiatives by government and private sector, the rural and remote areas continue to suffer from absence of quality healthcare. In most cases, people in the rural areas have to travel long distances to reach a doctor for basic healthcare services. This is also the reason why, not many people attend to their medical needs in the early stage of the disease cycle. They visit the doctor only when their condition turns serious. This also increases medical expenses, sometimes dragging the rural folk back into despair. Approximately 29 percent of India’s population (almost 300 million people), live below the poverty line and are highly dependent on free health services from the public sector. It is estimated that over 20million families get pushed below the poverty line every year because of healthcare expenditures alone. As a result, medical debts are the biggest non-productive source of debt in rural India. Telemedicine presents an opportunity to successfully manage a significant proportion of patients in remote locations, locally, with advice from specialists in the cities, without having to travel. This is also a key driver of public-private partnership (PPP) for health care delivery to the people of India. Telemedicine has the potential to take modern healthcare to remote areas where majority of diseases not requiring surgery are conducive to Telemedicine. It can also play a significant role in the training of medical personnel across the country. Decrease in price and complexity of the technology over the last five years ,makes it economically viable as well.

“Market opportunity in India is huge and we need to help doctors that are genuinely working in rural areas”



Opportunities and Challenges

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Address shortage of physicians

In India, the bias in healthcare delivery is evident from the fact that nearly 80% of physicians reside in urban areas, leaving the 72.2% rural population with limited access to healthcare services. Even as primary healthcare centres and makeshift dispensaries are being constructed at remote areas, the country experiences a perennial shortage of trained doctors and nurses. For instance, India has just one doctor for every 15,000 people, and specialists are even rarer. In the absence of qualified doctors, predominant healthcare personnel in rural areas are unqualified practitioners, who have either limited or no training. Doctors and hospitals are largely concentrated in cities, and as a consequence, health care in rural India is inadequate or absent. Telemedicine provides India a way to bridge this gap.

Opportunity in a wide range of applications

Telemedicine has the potential to change the health care industry by building bridges between clinicians and patients to overcome the barriers of distance and time, developing virtual communities that interacts and shares knowledge, improving access to health care in remote or isolated areas and enhancing continuity of care. Telemedicine generic applications include clinical applications, administrative applications, and educational applications.

Clinical applications include; handling urgent consultations, scheduled consultations, remote visits of patients, and the video reviews of certain studies done in advance.

Administrative applications covers; Telemedicine system for promoting and accelerating the replication, update and transfer of clinical information including medical records, examination data and financial information.

Educational applications include; applications that facilitate the process of sharing the material available for teaching and examination purposes in the medical field. Interesting cases from a conference room, auditorium and teleconference to physicians and residents scattered throughout the network are presented using this technology.

Telemedicine applications can be listed as Remote Consultation & Critical Care Monitoring, Second Opinion & Complex Interpretations, Disease Surveillance & Program tracking, Continuing Medical Education & Public Awareness, Disaster Management, Disease Management, Home Care & Ambulatory monitoring and Telementored procedures/Surgery – Robotics.

Widespread broadband

Telemedicine can be the future of Health IT, but it cannot fulfil its promise unless broadband internet is ubiquitous nationwide. Broadband is a big boost to Telemedicine. With the availability of broadband, India is now becoming a hot destination for Telemedicine as it is a win-win situation for both, the patients as well as hospitals. Telemedicine uses multimedia technology - video, voice, and data, to provide medical information, advice, and other medical services. With the development of video and data compression technologies and bandwidth, healthcare providers can deliver medical services from a distance. The lower cost of bandwidth and improvement in video and data compression standards have increased the number and types of medical services that can be delivered from a distance to include virtually every specialty. India is expected to move from 18th position in the world for broadband market and jump to attain the 6th rank while recording a CAGR of 489%. This is the highest growth rate expected from any market and is almost the double from the second highest growth market Vietnam (CAGR of 276%).

Growth of ICT industry

3G services roll out across the country offers great opportunity for Telemedicine market to grow within the next few years. 3G could be triggering a radical change in healthcare. Doctors are hoping that 3G technology will make Telemedicine consultation much smoother, giving patients a clear picture of whom they should consult.



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“Clarity in voice and video can make a huge difference”

Dr. Prathap C. Reddy, Chairman of Apollo Hospitals

3G technology has the potential to provide the next leap in Telemedicine. For instance, HealthNet Global Pvt. Ltd (HNG), a healthcare information technology solutions provider, has already designed a solution to enable 3G medical consultations over smart phones. The company plans to introduce the application in the market soon, in collaboration with Aircel Ltd., which currently runs a mobile healthcare service in collaboration with HNG in which callers can dial a number and get voice-based medical advice at a price.

According to Charles Antony, Chief Executive Officer of HNG, 3G videoconferencing takes Telemedicine a step further from voice-based consultation as it allows a doctor to see the patient. Sensing the potential for smart phone penetration, HNG has also developed about 500 mobile phone applications across different mobile platforms including Google’s Android and Nokia’s Symbian.

Sharp increase in mobile phone users : Statistics clearly suggest a huge opportunity for Telemedicine in India. According to CyberMedia Research, nearly 12 million smartphones are expected to be sold in India in 2011. As per Telecom Regulatory Authority of India (TRAI), India had a mobile-phone subscriber base of 825 million at the end of February 2011. Rural tele-density is projected to reach 200 million at the end of 2012, from 100 million in March 2010.

“India is a paradox,” says K. Ganapathy, President of Apollo Telemedicine Networking Foundation. Approximately 60 million customers are using mobile banking in India, he says, but there are few takers for mHealth services so far.

Case Study - Apollo Hospital

Apollo Hospital group has set up a 50-bed Telemedicine centre at Aragonda village (Andhra Pradesh, South India). It has also set up freestanding centres at Guwahati and Kolkata. These centres are equipped with facilities like CT- scan, X-ray, ECG and integrated laboratory and are linked to Apollo's specialized hospitals at Hyderabad, Chennai, and Delhi for seeking referral services, second opinion, post-acute care, interpretation services and health education. The hospital group also has a web portal, “ApolloLife”, that allows patients to interact with doctors via web and upload all their diagnostics and reports on the net.

Case Study - EHIRC

Escorts Heart Institute and Research Centre (EHIRC), Delhi, through its Escorts Heart Alert Service (EHAS), utilizes Telemedicine in establishing prompt contact with patients in distress. EHAS subscribers can record their ECGs at the time of discomfort through the cardiac beeper provided and transmit them through a telephone to the "heart alert centre". These tele-ECGs can be monitored 24 hours at the dedicated centre and fully equipped mobile cardiac care units from the centre can be rushed to provide intensive care to the patients before they are brought to the hospital for medical investigation.

Reduced costs of medical care

The ever rising cost of healthcare is becoming a prime concern. The incidental expenses related to patient care, i.e., the cost associated with factors other than the actual medical care, such as travel, accommodation for relatives, food, etc., also contribute substantially to the overall cost of treatment. In a country where health insurance is yet to catch up, all these are borne by patients, in some cases by selling property and livestock. If hospitals can reduce these costs associated with treatment, it would go a long way in reducing the burden of care on the patient. Telemedicine seems to be the answer for reducing the cost burden on the patients.



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Government Initiatives and public-private partnership

The Indian government has been investing in Telemedicine in a bid to make health care more accessible to the country’s rural communities. Both the public and the private sectors are devoting substantial amounts of money and effort to mainstream Telemedicine. Telemedicine is seen as a solution to some of the deficiencies in the country’s health sector. The Government’s 11th five year plan (2007-2012) allocated INR 2,000 million (USD 50 million) for Telemedicine. Most of the funding will be channeled through public-private partnerships. According to the Ministry of Health and Family Welfare, the necessary infrastructure, in the form of satellite or broadband connectivity, is already in place in large parts of the country, indicating a favourable situation for Telemedicine to grow.

Technology Development Program for Telemedicine by The Ministry of Information Technology aims to link three premier medical institutions - All India Institute of Medical Sciences, New Delhi, the Post Graduate Institute (PGI), Chandigarh, and the Sanjay Gandhi Medical Institute at Lucknow, for realizing telediagnosis, teleconsultancy and tele-education.

Improved and integrated healthcare

With an ageing population and the increasing prevalence of both chronic and long-term illnesses, the commissioning and delivery of integrated health and social care has become a significant challenge. Lifestyle and demographic change, rising incidence of chronic disease and unmet needs for more personalized care, demand a new and integrated approach to health and social care.

Over the next five to ten years, lifestyle diseases are expected to grow at a faster rate than infectious diseases in India, to result in an increase in cost per treatment. Telemedicine-wellness programs targeted at the workplace, where many sedentary jobs are contributing to an erosion of employees’ health, could help to reduce the rising incidence of lifestyle diseases. Advanced ICT provides a major new opportunity to realize care integration, superseding today's chain of disjoint responses to discrete threats to health. The need for new care models and technologies such as telehealth and telecare to support long-term care has never been greater. There is a need to promote such innovations as they challenge the system to focus on preventing ill health, supporting self-care, and delivering care closer to people’s homes. There is also a growing interest in telehealth solutions for managing long-term conditions such as heart failure, chronic obstructive pulmonary disease (COPD) and diabetes.

Healthcare franchises

One of the hot topics in developing countries is how to provide an array of health care services through what’s called social franchising. In social franchising models, NGOs create branded services that they then sell to entrepreneurs who provide them in their communities. It is an intervention that is designed to take advantage of market forces.

Case Study - World Health Partners

To address the shortage of affordable health care, a non-governmental organization (NGO), World Health Partners, is taking an innovative approach. World Health Partners looks for rural families to invest in its Telemedicine system. These families act as entrepreneurs, setting up a medical clinic. By investing in the system, they have a vested interest in promoting it, as well as maintaining required standards. The Telemedicine project represents a new approach to an old problem. In the case of the Uttar Pradesh Telemedicine project, World Health Partners has created and branded Telemedicine provision centres (TPCs) called SKY Health Centres. It sells franchises for these TPCs to selected families in the rural villages. The entrepreneurs invest about USD 3,000 in buying a franchise and in return are provided with furniture, a computer, satellite equipment, a generator, promotional materials, technical support, and training. The franchisees are carefully chosen to help meet program goals. Because the Telemedicine project especially focuses on women of childbearing age, providing them



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with basic health care and family planning support, World Health Partners sells the franchises to high school educated women who are highly involved in their communities. This helps to overcome some female patients’ reluctance to see or discuss reproductive health issues with male care providers. World Health Partners plans to expand the number of TPCs in India, first to 100 and eventually to 1,500 sites.

Timely intervention

Telemedicine allows for the patient's medical records to be transmitted to specialists. They can even be stored in an electronic format to be viewed later. For instance, a heart patient's electrocardiogram can be sent immediately for an expert view. This can help save a life, and that is only possible if you have a Telemedicine facility with data and voice capability. The cost associated with Telemedicine is negligible and it offers the right kind of diagnosis and care.

Emergence of cloud market

Cloud computing, also known as IaaS (Infrastructure as a Service) market is at a nascent stage, both globally and in India. Across industry segments, the Indian market has also expressed significant interest in the potential of IaaS services. Health care providers can use private or public cloud to store pathology and other reports (x-ray, etc.), maintain and store patient records/billing/claims, host third-party or in house applications (HMIS, etc.) and connect on a community level between doctors/hospitals, diagnostics companies, and patients.

Cloud market is projected to grow to USD 3 billion by 2015 and create 100,000 jobs in India.

A few players from the service provider segment such as Tata Communications, Wipro, and NetMagic have announced services which are likely to evolve into more stable cloud offerings. Tata Communications, for example, offers its customers an advanced virtualized environment with flexible arrangements to enhance capacity. Infrastructure providers of the cloud such as VMWare, NetApp and IBM have crystallized offerings for the private cloud and have taken proactive steps in educating consumers on the benefits of cloud IaaS services. The emergence of cloud market presents growth opportunities for Telemedicine in India.

Professional learning and training

There is a separate area of opportunities closely related to the distributed, networked use of specific specialized medical expertise but with a focus on the skills of the professional himself. Telemedicine provides a range of new possibilities to learn and train professionals by viewing real-life operations or sharing experiences with colleagues worldwide. Opportunities are also there to provide professionals with telemedical skills to be able to provide care through Telemedicine services to their patients.

Knowledge management and organizational learning

The recent resurgence of Telemedicine has the potential to start a trend towards virtual networking among health care parties. If it develops past isolated applications, Telemedicine will tend to evolve from ‘point-to-point’ connections towards more coordinated, integrated, and interoperable networks. These IT-enabled networks involve collaborations among multiple players across multiple sites and thus provide the foundation for the development of organizational learning communities. These communities can promote the knowledge acquisition, sharing, and creation, which would enable

“Adoption of cloud computing will help standardize the infrastructure for Health IT solutions in contrast to the current highly disparate situation”



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quality improvement and novel insights in the knowledge based health care delivery industry. Telemedicine can also be used for medical education, information gathering, data mining and management of the entire healthcare delivery system.

Reactive to preventive health care

Healthcare industry in India needs a shift from the current reactive health care system to a more proactive model that defends the patient and gives clinicians the information they need. Preventive care is not as effective as it could be. This is because the healthcare model is built around hospitals and clinicians waiting for sick people to come to them. Telemedicine presents an opportunity to shift the focus from the institution to the person. Telemedicine is a way to use technology to help assist prevention. Clinicians identify a risk and intervene before an emergency room visit is required. Patients gain access to information that can help them make smarter healthcare choices.

Challenges

Telemedicine holds great potential for reducing the variability of diagnoses as well as improving clinical management and delivery of health care services worldwide by enhancing access, quality, efficiency, and cost-effectiveness. In particular, Telemedicine can aid communities traditionally underserved, those in remote or rural areas with few health services and staff, because it overcomes distance and time barriers between healthcare providers and patients. It also provides important socioeconomic benefits to patients, families, health practitioners and the health system, including enhanced patient-provider communication and educational opportunities.

Despite its promise, Telemedicine applications have achieved varying levels of success. In both industrialized and developing countries, Telemedicine has yet to be consistently employed in the health care system to deliver routine services. Very few pilot projects have been able to sustain themselves once initial seed funding has ended. Several routinely cited challenges account for the lack of longevity in many Telemedicine endeavours.

Ashok Chandavarkar, Regional Manager, Intel Healthcare, Asia Pacific

Challenges faced by traditional methods are of scalability, cost, speed and reliable information. Other challenges are knowledge gap, business gap, financial gap and regulatory gaps. Some of them are discussed below:

Network Infrastructure

For healthcare to reach masses and to support the growing demand of healthcare services in India, India’s Telemedicine and mHealth infrastructure needs to undergo drastic changes. Indian Government has taken some initiatives aimed at providing affordable and quality healthcare services through setting up of primary health centres (PHC) all over the Country. However, the communications at these PHCs are not reliable and the internet speed of 33.6 kbps, at which these Primary Healthcare Centres get connected to the district or state level hospitals, is inadequate. Thus, PHCs are unable to support instant healthcare solutions to patients in remote villages through basic online information exchange or more advanced video transmission through Telemedicine.

“The various challenges faced in healthcare relates to the redundancy of data, time spent in administration work (which is around 60% of the total time) and problems faced during planning & scheduling phase”



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There is a need to build sustainable and cost effective infrastructure and ecosystem for implementing Telemedicine throughout the Country.

Rajendra Pratap Gupta, Chairman, Organizing Committee, International Telemedicine Congress & a leading Healthcare expert

mHealth will transform the lives of common people if there are adequate initiatives from both, the private and the public sector for development of ICT technologies in healthcare.

Costing

Financial cost poses a real challenge to the application and adoption of Telemedicine in India. Cost of providing healthcare to the large population of India is huge and introducing ICT would require an extra up-front investment. Hence, there is a need to manage the cost in such a way that the overall cost of healthcare goes down. It is also required to look at generating volume beneficiaries, for the costs to be justified.

There are not enough funds available for providing healthcare services to the masses. Equipment, transport, maintenance, and training costs of staff is huge. Moreover, convincing evidence to support the overall cost-effectiveness of particular Telemedicine strategies may be weak, while the economic implications of such strategies in different settings may not yet be known. One possible solution could be to pool resources from different government schemes and to create a fast and robust technology infrastructure fund that serves multiple verticals such as healthcare, education, finance, etc. This will not only help in overcoming high infrastructure costs but also create a synergy between different verticals while ensuring maximum utilization of existing infrastructure.

Incentives

Incentivizing all the stakeholders involved is a major challenge and raises the question of, “who will pay the bill”, as the cost of infrastructure, medical drugs, fees of doctors, and other operating costs could go very high. Hence, there is a need to divide these costs among different entities.

Ÿ Initial investment which usually is fairly large can be borne by the government, it will help drive the cause

Ÿ A physician must be motivated and incentivized in order to share medical records of his/her patient with other practitioners, as some doctors might not want to reveal their patient data

Ÿ In a third party financing solution, there is a chance that people may deceive the system by duplicating the same procedure over and over again, which would lead to unnecessary cost overrun

Linguistic and socio-cultural diversity

Another barrier to the rapid delivery of equitable care is linguistic diversity. For example, in India, there are over 22 officially recognized languages and over 1600 “mother tongues”. Linguistic diversity seems a major barrier in the way of a patient in one region being able to talk to a doctor in another region.

“Once the industry is able to give clinical evidence, eHealth & mHealth market will explode”



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Another major contributing factor to Telemedicine failure is the oversight of incompatible cultural subsystems that prevent the transfer of knowledge from one cultural context to another. Medical professionals in the industrialized world may be unfamiliar with the available facilities and alternative management strategies in remote areas and vice versa. Without a good understanding of the local context, it may be difficult to integrate Telemedicine in a useful way.

Power disruptions

More than 44% of rural India faces power cuts of 12 to 15 hours a day, where even a battery backup system does not work-out. Thus, while most modern technologies designed for developed countries assume continuous availability of power and telecom connectivity, it takes time and cost to customize them to address such gaps for developing countries

Education

Telemedicine is not just about providing healthcare service when someone is unwell, but to also be used to promote preventive healthcare to improve the standard of living and reduce costs in the medium to long term. This will also help in improving and enabling higher productivity. But achieving this requires bringing people into the system and educating them about the different preventive measures to avoid disease outbreaks like Swine-flu or other seasonal diseases.

Managing information

Health information exchange needs to be demand driven with proper access and control mechanism in place. Challenge is to motivate and encourage key stakeholders like patient, medical service provider, insurance companies, and government, to pull as well as push right kind of information from the system.

All the information that has been collected should be media rich (containing video, image, text, etc.). This information should be properly archived and should be accessible, retrievable, secure and readable from a remote location using different technology platforms. One patient-one record needs to be implemented, so as to avoid duplication of information. Innovative and cost effective health informatics solutions need to be created for the purpose.

Adoption and resistance

In India and across the globe, there is a problem of reluctance on the part of patient as well as doctors, in adopting mHealth and Telemedicine. There is a need to bring in the right kind of technology in the right way so that patients as well as doctors feel comfortable in using them. This could work as an ultimate test of technology, as companies not only have to prepare the best technological systems but also make sure that they are easy to understand and use.

Staffing at different levels

Local skills, knowledge, and resources may also limit the application of Telemedicine in developing countries. A lack of computer literate workers with expertise in managing computer services, combined with the lengthy process required to master computer-based peripheral medical instruments, can hinder uptake of Telemedicine.

mHealth is not just about having technology in place, it should also have an identifiable, approachable and well qualified human interface to interact with. Getting the right kind of people to use these technologies in order to provide proper healthcare services is very important. Hence, there is a need to hire right kind of people and train them properly so that they are well equipped to carry out the task of providing healthcare in remote areas.



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Over 500 delegates from over 20 countries participated in the 2011 Telemedicine congress event held

at Hotel Westin, Mumbai in India. Distinguished guests/speakers like Mr. Aneesh Chopra, CTO and

Assistant to the President, US; Shri Sachin Pilot,Hon’ble Minster of State for IT, Government of India; Dr.

Prathap Reddy, Chairman, Apollo Hospitals Group; and Shri Shankar Aggarwal, Additional Secretary,

DIT, Government of India, Lord Nigel Crisp & Dr.Dale Alverson besides a host of global healthcare

leaders, made this event phenomenal in the Healthcare Industry. The entire Telemedicine ecosystem,

including Telecom Operators, Telecom equipment manufacturers, Mobile handset manufacturers,

Software vendors, Policy Makers, and Healthcare professionals participated. These people shared their

views on Telemedicine industry. They are the movers and shakers of the industry and this is what they

have to say:

Dr. Prathap C. Reddy, Chairman of Apollo Hospitals Group

He stated that we must understand how to make Telemedicine succeed. The most important thing is to

make doctors and patients understand the significance of Telemedicine. Secondly, connectivity plays a

very important role in its success. According to him, Apollo has the one of the best Health Information

System and we are ready to take it to sustainable stage. So now only an increased level of acceptance of

doctors and patients is needed.

In India, we are facing issues like real lifestyle diseases (diabetes, cancer etc.). A global platform is

required to address these issues and the answer lies in Telemedicine. He stressed on the fact that a

common platform with the help of various players in the value chain would improve the systems. India

has increased possibility to shift focus from hospitals to clinics to home. Concepts like eICU can help in

improving intensive care in regions where specialist doctors are not available.

“Telemedicine can fill the gap of accessibility of healthcare for all”



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Vishal Gupta, Vice President, and Head of Global Services Practice (GSP)& Healthcare Practice East, CISCO

He spoke about Cisco Health Presence, which is an initiative in partnership with Apollo Healthcare Group that focuses on sharing information and experience. A larger number of patients can be treated effectively, regardless of the distance, if both the factors are taken into consideration. We need to think about policies and practices to move from pilot phase to scalable phase. According to him, Telemedicine 2.0 focuses on moving from isolated care to integrated care, from point focus to helping all stake holders, from individual efforts to ecosystem partnership, and lastly from CSR driven to economically sustainable projects. Chronic diseases in India have increased and there is not much access to the technology in rural or semi-urban areas. He stressed on the fact that patient education is required.

Ashok Chandavarkar, Regional Manager, Intel Healthcare, Asia Pacific,

According to him, vision of Intel is to create and extend computer technology to connect and enrich the life of every person. The Intel 1MX15Health Program focuses on enabling one million people with healthcare, education etc. till 2015. Tools used in this program include Intel PC basics, Intel Easy Steps, Skoool healthcare education, etc. All these are open access services.

He stressed on the challenges faced in healthcare sector due to redundancy of data, time spent in administration work (approximately 60% of the total time) and problems faced during planning and scheduling phase. Ashok also pointed out major problems areas in the field of training including excessive relying on classroom based learning, no assessment of the training that’s been provided, and retention of knowledge, which is not certain. He also stated about the pilot initiatives that were undertaken by Intel like the one in Tamil Nadu in 2009, which did not worked because of administration problems.

Dr. Gautam Sen, Chairman, HealthSpring Community Medical Centres

He said that, so far very little has been done in Healthcare using IT. IT has not created a big impact on healthcare similar to what it has created in banking or other sectors. Very few clinical software and decision support software are available. Most of the appliances are not very user friendly and consumers find them tough to use.

Gautam also stated that advancement is more in tertiary level healthcare system and not in rural and semi-urban areas. According to him, technology should help for a larger cause like there should be something to check calorie intake.

Raja Rajamannar, Chief Executive International, and Chief Innovationand Marketing Officer, Humana Inc.

According to him, mobile phone can do lot more like medicine reminders, etc. Mobile applications can also monitor health progress, helping to shift consumer behaviours toward managing wellness rather than treating sickness. Reflecting the growing use of mobile technology by physicians, Humana is developing a specialized in-home scale for chronic heart patients to connect with physicians in real-time. Patients can step on the scale at home and deliver live data, such as weight, blood pressure and blood-glucose levels, directly to their primary care physician.

“Technology is an enabler and it is important that knowledge should be shared”

“Mobile phone is under-utilized, and it can do lot more”

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Humana has also developed games for kids to motivate children to take medications. They are also

exploring how video games can help spur healthy habits DIDGET, an FDA-approved blood-glucose

monitoring system for Humana pediatric patients, is being rolled out with Bayer Healthcare. It plugs

into Nintendo DS or Nintendo DS Lite systems and awards points to users for testing their glucose levels.

Points are used to unlock new game levels and buy items inside the game.

Girish Rao, Managing Director, Vidal Health

Cost effective solutions needs to be created for disease management. In addition, self-motivation and

awareness for patients is also very important.

A survey was conducted in a mid-sized IT company and the results were alarming. In risk profiling, a big

portion falls in medium risk level and they would move to high risk level in the future, majorly because

of their dietary issues. He stressed on the fact that 100% people do not follow good dietary habits. To

prevent chronic diseases it’s very important to check the lifestyle of a person at regular intervals.

Management needs to play a major role for the health of their employees.

Dr. Surendra Gupta, Chairman, Alere India

Approximately 80% of the cost of chronic diseases comes when a disease moves from preventive stage

to advanced stage (cure stage). If we can monitor and take preventive procedures, it will save costs.

He stated about the products and solutions Alere has brought into the US market and plans to bring

some of them to India in 2012

Laurens van der Tang, CEO, VitalHealth Software, Netherlands

According to him, healthcare should be based on the individual needs of a patient and IT companies like

VitalHealth Software are helping to provide personalized health management.

He also mentioned about VitalHealth Software’s products and services like; EMR application designed

in a new way for iPad, online therapy for depressions, etc.

Dr. Pramod K. Gaur, Vice President, UnitedHealth Group, USA

He focussed on the importance of access of healthcare and its affordability for all. Consumer, care

providers, sponsors, and the government are the concern parties and everyone has to play their role.

According to him, innovation is the key in dealing with various kinds of issues faced by Telemedicine.

Dr. Nitin Verma, Vice President, Healthfore

He believes that inequality in primary healthcare is a major concern.

Nitin also focussed on the fact that India has technology but is not able to utilize it to its optimum level.

He compared India not only to developed countries but also to developing countries and showed that

India lags behind Sri Lanka in many terms in the field of healthcare.

“Technology has changed a lot of things in sectors such as banking

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According to him, major challenges faced by traditional methods include scalability, cost, speed, and reliable information.

Nitin mentioned about the mobile revolution that hit India and the launch of MediPhone, which started as a pilot project in Haryana in March 2011 in partnership with Airtel. Currently, they receive approximately 28,500 calls a day. 95% of the calls received are for triage services and the rest for health education. 85% of the callers are male.

Dr. Anand Vinekar, Head, Department of Pediatric Retina & Pediatric Visual Rehabilitation, Narayana Nethralaya

He stated that 60% of India’s population is unconnected with medical attention, 30% is poorly connected and underserved, while remaining 10% is well connected and over served. The 60% category resembles rural India, 30% resembles cities, and the remaining 10% is urban India.

He also discussed about Teleophthalmology and The Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) initiative which was initiated in 2008. KIDROP provides Retinopathy of Prematurity screening for rural and semi-urban infants in hitherto unscreened centres using the backbone of Teleopthalmology and Wide-Field-Digital Imaging devices. KIDROP has trained technicians to screen infants in the peripheral centres (where no specialists exist) using the Retcam Shuttle (Clarity MSI, US) and store, read, analyse, grade and upload these images from the rural centre itself using an indigenously developed internet based PACS system, which also delivers these images live to the remote expert on his iPhone or PC or iPad and receives live reports delivered through the internet based server, for the technician to read and provide.

Dr. H.S. Rissam, Governor, Medical Council of India (MCI)

He believes that healthcare must reach the door steps and that initiatives should not be left at pilot phase. Some steps have to be taken to convert these into practices.

Rissam also stressed on involving ‘big people’ in all the activities of Telemedicine, because when major players are involved, success automatically follows.

In health education sector, one of the major issues is that of shortage of faculty. This can be resolved by tele-education. It can bring faculties to universities where they cannot physically be present.

Dr. Brian Holcroft, Representative, Eykona

He emphasized the importance of cost effective and easy to use technology, focusing on hand held 3D imaging, and repeatable wound measurement and personal computer software to reconstruct 3D model for viewing and measuring purposes.

Dr. Selva Kumar, Representative, Sri Ramachandra University (SRMC)

Selva stated that there is a shortage of specialist in India (like only 1,000 neurosurgeons are there in India as compared to 22,000 in Japan). Hence, Telemedicine has a bigger role to play in India.

Selva also discussed about various case studies like Arogya Sudha, a tie up with Southern railways to treat patients in train during journey.

Mr. S.G. Prasad, Chief of Telemedicine, Care Foundation

He stated that, even though large population in India lives in rural area still they have lesser access to medical facilities, and too much is available to too few. There is a need to integrate medical technology, information technology and communication technology.



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He also emphasised on the need for a common platform for all the applications, like ECG, Stethoscope, BP, etc. with the help of interfaces like DICOM, RS232 etc.

IT requirements changes every day. So there is a need to benchmark all the requirements.

According to him, Telemedicine becomes even more cost effective as most of the cases require only one visit and in these cases, there is no need for any personal face to face appointment with the doctors.

Marc Alexis Remond, Global Director of Government Solutions and Market Development, Polycom

Marc stressed on the importance of mHealth, and cloud computing. He also talked about the global explosion of three technologies in the near future: mobile devices, video consumption, and social networks and their positive impact on Telemedicine.

He emphasized on collaborative healthcare by setting up the relationship between district hospitals, rural clinics, nursing homes, patient’s home, CSC & CHC, prisons, schools, universities, enterprises, etc. India is also moving from a connected to a collaborative healthcare system by providing both real time data and partnering within the ecosystem like with vendors, government, services providers, etc.

Dr. Madhusudan Chauhan, JIVA Group

According to him, the two parts of problem that exist are infrastructural problem and growing incidents of lifestyle disorders; and Ayurveda with technology can be the solution to it. Hence, they started with Jiva Telecentre, where doctors give advice on phone, and even medicines are delivered at doorsteps of the patients.

Jiva is the world’s largest Ayurveda telecentre where they consult over 6,000 patients’ daily, suffering from diabetes, obesity, migraine, etc. Currently, they reach out to approximately 1,500 towns and cities.

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There are certain things in the arena of Telemedicine that only governments can do. Indian Government can learn from the successful methods and models adopted in developed world. Example, US makes data available in areas like government spending, community health, medical knowledge, consumer product information, provider directories and quality in its initiative of open health data. According to Aneesh Chopra, Chief Technology Officer, and Assistant to the US President, “If data is made open access, information can be made easily and readily available”. In US, an open platform is provided (Blue button), to the citizens where they can input their health details and can access their data from anywhere in the world.

Blue Button Initiative

In 2010, the Veterans Administration launched the Blue Button, a standards format that allows simple exchange of a patient's personal health data. Initially designed for use by veterans, the idea has taken off in the private sector and has been supported by at least one major care provider overseas.

With Blue Button, the government is making sure citizens have easy and safe access to their data and showing how others in the private sector can do the same things for their patients, giving them access and control of their care.

So far, at least 60 private organizations have pledged to adopt Blue Button, according to the Department of Health and Human Services. Current nationwide users include Kaiser Permanente, McKesson, Microsoft Healthvault, Aetna and United Health Group. As of this fall, more than 600,000 Americans have used Blue Button to download their health records.

Telemedicine is creating business models that unlock access to new players and technologies that support preventative, acute and chronic care.

Functional Model

Traditionally, health care as a business depends on the number of patients treated rather than the quality of output delivered. The quality of tr eatment however is factored into the costs, thereby placing prime importance on operational efficiencies. The Functional model is based on providing remote monitoring and treatment solutions. These solutions are aimed at providing all important data



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needed for the doctor to take decisions regarding patients who may not need to make a visit to the clinic/hospital. This business models aims at reducing costs for hospitals and patients whilst boosting revenues in terms of number of patients treated per unit time. This model also improves medical treatment by facilitating extensive continuous monitoring capabilities of chronic patients from their residences as well as lesser waiting time and appointment fixing issues faced by patients who otherwise postpone treatment. Some of the challenges faced by this model are in terms of fear of reduced interaction.

Delivery Model

This business model is largely dependent on the services and products that facilitate better healthcare for all players involved. From manufacturing dedicated mobile devices, remote diagnostic and treatment equipment, to providing mobile applications, this space is largely dependent of the need satisfied in the market and the stake holder it is targeted at. Dedicated mobile devices can help chronic patients who need regular check-ups, and remote monitoring devices help in setting up of mobile clinics and increasing the reach of deliverable healthcare. Mobile applications are the most attractive area in which the content delivery and service offered has prime importance and investments are limited to software development and marketing. These "Apps" can cater to the insurance company, the practitioner, the patient or the medical establishments, in terms of interconnectivity and value added service offered.

Structural Model

Whilst Telemedicine hinges on connectivity and data transfer, it is largely dependent on an infrastructure that can facilitate the same. This business model aims at satisfying various facets of the infrastructural requirement and challenges posed by Telemedicine. The multi-fold infrastructural requirements of Telemedicine can be classified into: Connectivity, Security, and Data management requirements. Bandwidth and high speed data transfer technology are the immediate critical needs in offering Telemedicine services. The provision of these facilities can be taken up by telecom vendors and service providers. Data security is one of the biggest fear in the mind of patients when availing Telemedicine services. Protecting critical patient data and establishing rugged access control systems is needed for the buy in of consumers to feel safe in availing Telemedicine services. Telemedicine offers increased connectivity and also provides huge amounts of data previously unavailable. The management of this data and integration of all the services into hospital IT systems is another infrastructural challenge this business model looks at.

Chart 10 : Business Models

Functional

Delivery

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Appropriate training of Telemedicine personnel results in increased utilization of the system, improved data collection capabilities, and greater confidence in diagnosis when relying on data collected through Telemedicine technologies. Surprisingly, successful Telemedicine programs underscore the importance of training to achieve success.

The Telemedicine technology should be easy to use to an extent that it actually encourages use. End-user training should be a function of minutes. Advanced users should be fluent with the system within 30 minutes. In order to address uncertainty and build confidence in using new technology, it's critical that both doctors and patients have access to quality training in how to use technologies involved in Telemedicine. If there is a new technology, it is important for proper information to be communicated about the product. If doctors and patients are aware of what Telemedicine is and how it is used in medical interaction, this will reduce uncertainty in many ways. For example, if a patient has a question about technology, the doctor should have the proper knowledge to adequately answer the patient. Not only knowing what the technology is, but how it is used, is also important for the successful adoption of technology into the medical world. Knowing is only half the battle, doctors and patients must also be competent with the use of technology. This leads to proper use of Telemedicine to facilitate communication between doctors and patients.

Everyone is affected by the use of technology in the medical field, especially as it impacts doctor-patient communication. Therefore, targeted communication interventions for medical professionals and their patients must become a part of health care culture. It is important to not only know what these technologies are and how they are used, but also to understand how the use of technology, or Telemedicine impacts relationships with doctors, which in turn, can influence a patient's personal health. Because medical education and training has always been important in health care, this notion is ever more important as technologies continue to change and impact everyday lives, which in turn propel society forward. Below is a list of the training programmes offered by the key stakeholders driving the growth of Telemedicine in India.

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The School of Telemedicine & Biomedical Informatics

The Institute has been established by Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, with the financial support from the Government of Uttar Pradesh and the Department of IT, Ministry of Communication and IT, Government of India. The objective is to create human resources in various fields of Health IT; including Telemedicine, hospital information management system, public health informatics, nursing informatics, digital medical library, medical multimedia and animation, bioinformatics, medical imaging informatics, cancer informatics, artificial intelligence and clinical decision support system in medicine, e-learning in medicine, surgical informatics, virtual reality and medical simulation, etc. This is the first academic institution of its kind dedicated exclusively to the emerging arena of healthcare informatics in a public funded academic medical institutional setup. Diploma courses of one year duration in five disciplines including Telemedicine, hospital information system, public health informatics, nursing informatics and digital medical library started in the academic year 2009. All these courses are duly approved by the Statutory Bodies of the Institute, and the diploma is be provided by the SGPGIMS.

Teletraining Centre at National Institute of Health and Family Welfare, New Delhi

The Ministry of Health & Family Welfare, Government of India, is setting up a teletraining centre at the National Institute of Health and Family Welfare in New Delhi, to create a facility that will offer teletraining to public health professionals across the country through various e-learning modules. This will enable professionals to switch to more efficient electronic modes from the currently practiced on-site training modules. This initiative will boost capacity building in public health which has been visualized under the National Rural Health Mission.

Centre for Development for Advanced Computing (CDAC), Pune

The Postgraduate Diploma in Healthcare Informatics (PGDHI) run by CDAC, Pune, is a 24 weeks full time program targeted towards grooming students in the area of Healthcare Informatics. The objective of this course is to enable the student to understand the art and applicable science of introducing, managing, organizing information and technologies related to human healthcare as well as making it useful for problem solving using latest state-of-art technologies. The course enables students to understand the concepts in Healthcare informatics, learn the technologies and issues involved in aggregation and analysis of information relating to various factors interacting in healthcare. It equips the students with the skill set to apply appropriate techniques to solve problems in various application areas in healthcare informatics.

Space Hospitals in alliance with Kaashyap Technologies Limited

Kaashyap Technologies Limited has partnered with Space Hospitals to provide training in Telemedicine and medical informatics. The Hospital offers PG diploma in Telemedicine and medical informatics catering to the growing need for tech-savvy professionals in Telemedicine and medical informatics. This course attempts to bridge the gap between healthcare professionals and medical technology.

Sir Ganga Ram Hospital

The Hospital has strengthened their academic activities by initiating a new project of Teleducation in the hospital to share academic programmes and live surgery transmission with other institutions using videoconferencing equipment and Integrated Services Digital Network (ISDN) lines. At present, Sir Ganga Ram Hospital runs Diploma in National Board (DNB) courses for 28 specialities recognized by the National Board of Examination, New Delhi. Besides academics, the Hospital also provide Teleducation programmes on various health issues to generate awareness by sharing views in CMEs, workshops, seminars etc.

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Amrita Institute of Medical Science (AIMS)

AIMS has been providing care through Telemedicine since 2003, servicing remote islands such as Lakshadweep and Andaman-Nicobar, as well as Leh-Ladakh in Kashmir. Currently, more than 32 centres in India are connected with AIMS. The Institute has used the technology to provide specialty medical support during times of natural disasters, including the 2004 Indian Ocean Tsunami and 2008 Bihar floods.

AIMS uses its Telemedicine link to educate doctors in remote primary centres with the latest medical advancement through seminars, workshops and teaching programs. AIMS’ videoconferencing also opened up new possibilities for continuing medical education or training for isolated or rural health practitioners, who may not be able to leave a rural practice to take part in professional meetings or educational opportunities.

AIMS DNB teaching programs is telecasted to other Telemedicine centres, like Tiruvananthapuram Medical College. AIMS also offers live interaction of CME programs with various Telemedicine centres.

Sri Ramachandra Medical College & Research Institute

The Institute offers Telemedicine service to GB Pant Hospital located in Port Blair, Andaman & Nicobar Island, where they do not have super speciality services like neurology, neurosurgery, cardiology, cardiac surgery, nephrology, urology, medical gastro enterology, surgical gastro enterology, plastic surgery, etc. Major trauma cases like road accident and critical pregnancy cases are also discussed through Telemedicine.

Sri Ramachandra Medical College has been recognized by WHO to provide training to WHO fellows for Telemedicine. SRMC have trained teams from North Korea and Maldives consisting of doctors and IT professionals.

Apollo Telemedicine Network Foundation

Apollo Telemedicine Network Foundation, in collaboration with Anna University in Chennai, was the first to start a 15 day certification course in Telehealth Technology, which provides technical, medical and managerial skills. The first course commenced in October 2003. As part of its efforts to popularize Telemedicine, an interactive section on Telemedicine has been made available in the division of emerging technologies at the renowned National Science Centre in New Delhi.

VRC28 by ISRO

The Village Resource Centre VRC28 concept has been evolved by ISRO to provide a variety of services such as tele-education, Telemedicine, online decision support, interactive farmers' advisory services, telefishery, e-governance services, weather services and water management. VRCs act as learning centres focused on the virtual community. At the same time, VRCs also provide connectivity to specialty hospitals, thus bringing the services of expert doctors closer to villages.

Resource centres are organizations that actively promote and encourage development, advancement and research in the science of Telemedicine and its associated fields. These Centres arrange regular scientific meetings, symposia, seminars and workshops to create public awareness and promote the use of Telemedicine in India and globally. They also focus on training of students, health professional, research fellows and technicians; and disseminating knowledge in Telemedicine field by publishing brochures, periodicals, and journals in various aspects of Health IT. Some of these prominent Centres are as detailed below:

Resource Centres in Telemedicine

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Telemedicine Society of India (TSI)

It is a not-for-profit society formed in the year 2001 by senior scientists of Indian Space Research Organization (ISRO), senior doctors from various national level institutes and senior officials of the Ministry of Health and Ministry of Information Technology. For the past ten years, TSI has promoted the practice of Telemedicine and mHealth; spreading awareness and updating the users, providers, and patients on the benefits of using Telehealth and mHealth in healthcare delivery.

International Telecommunication Union (ITU)

It is the leading United Nations agency for ICT issues, and the global focal point for governments and the private sector in developing networks and services. For 145 years, ITU has coordinated the shared global use of the radio spectrum, promoted international cooperation in assigning satellite orbits, worked to improve telecommunication infrastructure in the developing world, established the worldwide standards that promote seamless interconnection of a vast range of communications systems and addressed the global challenges of our times, such as mitigating the impact of natural disasters and climate change and strengthening cyber security.

ITU also organizes worldwide and regional exhibitions and forums such as ITU Telecom World, bringing together the most influential representatives of government and the telecommunications and ICT industry to exchange ideas, knowledge and technology for the benefit of the global community, and in particular the developing world.

The Indian Association for Medical Informatics (IAMI)

It is a non-government organization started at Hyderabad in 1993 with the help of scientists and doctors. Its members hold key positions in major public and private sector health care institutions and constitute the actual decision makers in policy issues relating to IT applications in healthcare. IAMI has been holding regular conferences and regional meetings and has a highly vocal and vibrant online discussion group where all matters relating to IT in healthcare, including Telemedicine and e-health are presented and discussed.

WHO - eHealth Standardization Coordination Group

eHSCG, is a platform to promote stronger coordination amongst the key players in all technical areas of e-health standardization. The Group is a place for exchange of information and will work towards the creation of cooperation mechanisms to :

ŸIdentify areas where further standardization is required and try to identify responsibilities for such activities

ŸProvide guidance for implementations and case studies

ŸConsider the requirements of appropriate development paths for health profiles of existing standards from different sources in order to provide functional sets for key health applications

ŸSupport activities to increase user awareness of the existing standards, and case studies

DMAI - Disease Management Association of India

Disease Management Association of India (DMAI - The Population Health Improvement Alliance) is formed by Executives from the Global Healthcare industry to bring all the stake holders of healthcare on one platform. DMAI is building the knowledge pool to contribute & convert ‘Ideas’ into ‘Reality’ for healthcare in India. DMAI is the only not-for-profit organization focussed on population health improvement in India.

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‘Preventive Care’ and ‘chronic disease management’ have to become an integral part of the Indian healthcare system. DMAI is currently focussed on the following mentioned initiatives and thanks its partners for supporting the programs initiated by DMAI.

HIMSS

HIMSS is a cause-based; not-for-profit organization, exclusively focused on providing global leadership for the optimal use of information technology (IT) and management systems for the betterment of healthcare. Founded 50 years ago, HIMSS and its related organizations are headquartered in Chicago with additional offices in the United States, Europe and Asia. HIMSS represents more than 38,000 individual members, of which more than two thirds work in healthcare provider, governmental and not-for-profit organizations.

HIMSS frames and leads healthcare practices and public policy through its content expertise, professional development, research initiatives, and media vehicles designed to promote information and management systems' contributions to improving the quality, safety, access, and cost-effectiveness of patient care.

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Continua Health Alliance and Telemedicine Society of India (TSI)

“Continua focusing its efforts on India reinforce the fact that India is a huge market, and that healthcare entrepreneurs, who develop clever products to improve personal health care, now have a global opportunity they can tap into”

Continua Health Alliance has joined hands with the Telemedicine Society of India (TSI), by launching the Continua-India working group at the International Telemedicine Congress 2011 (Telemedicon ’11) held in Mumbai fr om November 11-13.

The Alliance is dedicated to establishing a system of interoperable personal connected healthcare solutions and leveraging technology for chronic condition management, a critical issue for India and many other nations.

Rajendra Pratap Gupta, Chairman, Organizing Committee, International Telemedicine Congress & a leading Healthcare expert

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About Continua Health Alliance

Continua Health Alliance is an international

non-profit, open industry group of nearly

240 healthcare providers, communi -

cations, medical, and fitness device

companies. Its members aim to develop a

system to deliver personal and individual

healthcare. The objective of developing

products and solutions is to promote

delivery of healthcare in the home

providing independence, empowering

individuals, and providing the opportunity

for truly personalized health and wellness

management.

The technology platforms for these

products and services are defined by the

members and published in the Continua

guidelines. Products made under Continua

guidelines aims to provide consumers with

increased assurance of interoperability

between devices and

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Continua’s influence

According to G. Venkatesh, Chief Technology and Strategy officer at Sasken and Continua Member, worldwide there are approximately one billion adults that fall under the category of overweight and 860 mi llion individuals with chronic conditions. It’s also surprising to note that out of the entire population that suffer from diabetes, 91% are those that fall in the category of modifiable contributor and only 9% are non-modifiable contributor. Similarly, 83% of heart diseases come from modifiable contributors. Remote monitoring of patients is helping individuals with chronic conditions and some of the positive results include, 35-56% reduction in mortality, 47% reduction in risk of hospitalization, and six days reduction in length of hospital admissions.

Continua wants to develop a market with government programs which will accelerate the ability to connect patients, doctors and other members of the ecosystem. It also emphasized on the need of homogenous efforts which will help in reducing duplication of efforts and reduction in cost. According to Continua, the structure created should include all parts of society and have a united voice for the emerging markets and Continua will act as a place where these needs could be met. As a member of Continua, one can be a part of market development group and will be able to formulate and regulate policies. The six units of continua includes technical group, used cases group, testing group, market developing group, and policies and regulation making group.

Continua’s take on India

Market opportunity in India is huge but there are not many big players because of limitations to reach rural areas, and unprepared business models. Rural areas are missing accessibility, quality care and proper channels. Organizations needs to be identified who are interested in collaboration with doctors. Continua also believes that many doctors are not comfortable of too much data, so streamlining should also be done.

The panel opined that funding is limited, with government funding being the only source. They said that investments by venture capital companies in this segment would prove very critical.

If India wishes to go global, it’s important to make all devices linked. It is also important to lay down standard guidelines. Steps like encouraging young entrepreneur, building mentoring networks, etc., should be taken.

Disease Management Association of India (DMAI) and Continua Health Alliance will co-host and incubate three ideas in Telemedicine to address rural health, Non Communicable Diseases (NCD), and health education and awareness.

About Continua Health Alliance (Cont’d)

Through collaborations with gover -nment agencies and other regulatory bodies, Continua works to provide guidelines for the effective management of diverse products and services from a global network of vendors.

The Organization is w orking toward establishing systems of interoperable telehealth devices and services in thr ee major categories: chronic disease management, aging independe-ntly, and health & physical fitness.

To organize its work, Continua segments the market into three domains :

ŸLiving independently longerŸWellnessŸManaging chronic conditions

Continua's Board of Directors is currently composed of the fo l lowing companies: Inte l Corporation, Roche Diagnostics, Partners HealthCare, Pr ice Waterhouse Coopers, Ascension Health Inc., Cisco Systems, Kaiser P e r m a n e n t e , M e d t r o n i c , Panasonic, Philips, Qualcomm, Samsung Electronics, and Sharp.

Speakers from Continua in Telemedicon’ 11 included:

ŸMr Sameer Sawarkar, CEO and Founder of Neurosynaptic

ŸDr. Yogesh Patil, CEO of Biosense

ŸDr. B.S. Bedi, Advisor to Centre for Development of Advanced Computing, under Ministry of Communication & IT, for Health Informat ics , Te lehea l th , Medical

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Indian Telemedicine has come a long way since India's first Telemedicine centre at Apollo Aragonda Hospital was inaugurated by the then US President, Bill Clinton in 2000 in the state of Andhra Pradesh. Today, there are about 500 Telemedicine centres linked with about 50 specialist hospitals across the country. The centres, operated by a mix of private hospitals, state and union governments, and public-private partnerships, have so far provided teleconsultations to an estimated 0.15 million patients. The government has also made a major commitment to the growth of Telemedicine. ISRO has already connected 25 major hospitals in the mainland and plans to link at least 650 district hospitals. It also plans to establish 100 more Telemedicine centres across the country in the next few years.

Rajendra Pratap Gupta, Chairman, Organizing Committee, Telemedicon’11

“Way forward for state governments In mHealth & Telemedicine is to start with health call centers, establish telepathology, teleradiology, tele-referral centers and focus on some critical areas like tele-psychiatry, teledermatology & geriatric care, where the need gap is maximum”R

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The government also is reducing import tariffs on infrastructure equipment. And while India has yet to pass legislation on Telemedicine related issues, the Ministry of Information Technology has developed “Recommended Guidelines & Standards for Practice of Telemedicine”, with the goal of standardizing digital communication in Telemedicine. Also, Under National Rural Health Mission, government has kept a budget of INR 10 million per annum for each state to increase Telemedicine service centres.


The government is also focused on increasing Telemedicine capabilities in India. The 11th five year plan (2007-2012) allocated 2,000 million rupees (about USD 50 million) to Telemedicine. Most of the funding will be channeled through public-private partnerships. According to the Ministry of Health and Family Welfare, the necessary infrastructure in the form of satellite or broadband connectivity is already in place in large parts of the country.

Efforts are taking place in the field of medical e-learning by establishing digital medical libraries. Some institutions that are actively involved in Telemedicine activities have started curriculum and non-curriculum Telemedicine training programs. To support Telemedicine activities within the country, the Department of Information Technology has defined the Standards for Telemedicine Systems and the Ministry of Health & Family Welfare has constituted the National Telemedicine Task Force. There are various government and private Telemedicine solution providers and a few societies and associations actively engaged to create awareness about Telemedicine within the country. The ultimate aim is to connect all inaccessible parts of India.

While rural India is still dealing with lack of basic healthcare, telecommunication infrastructure in the country has seen remarkable progress. Access to broadband internet connectivity in rural areas is steadily increasing and the adoption and penetration of internet has shown tremendous growth. The advances in medical science and ICT offer wide opportunities for Telemedicine. The Internet is playing a pivotal role in providing cost-effective healthcare to a widely dispersed population, through Telemedicine. Sustained efforts from both the Government and private sector can help create uniformity in healthcare availability. To capitalize on technology investments now and in the future, rural hospitals need an integrated IT network that helps diverse entities to collaborate and communicate effectively. However there are few challenges to realize the rural Telemedicine potential.

The start-up costs, involving both, manpower and expensive technological equipment, are substantial. So far, the private hospitals involved have covered most of the bill but this model of operation is not sustainable

Ÿ Consultation cost is also a major concern. Generally a consultation session with private hospital doctors costs around INR 1,000, which is too steep a price for majority of the Indians who earn less than INR 100/day

Ÿ Making the drugs recommended by doctors available to patients in remote locations is also a major issue

Ÿ Telemedicine also has limitations when it comes to diagnosis and surgeryŸ Apprehensive doctors who are used to orthodox methods of treatment are still not

comfortable with the concept of Telemedicine

The appropriate use of Telemedicine can redress the problems of equal accessibility and geographical variations in quality while keeping costs in check. There has to be a smart balance between total

“It is a fact that most of the infant deaths in India are due to lack of timely reporting of the condition, because of which timely interventions cannot happen. So mHealth can help in reducing IM & MM”



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dependence on computer solutions and the use of human intelligence. Striking that balance may make all the difference in saving someone’s life. The growth of Telemedicine is based on the successful fusion of Telemedicine into the traditional healthcare delivery system. The future of Telemedicine will be shaped by such things as quantifying evidence-based clinical outcomes and costs, and assimilating advances in technology.

They are many pilot projects which have already been implemented, but Telemedicine is still facing challenges to take it to the next level. Nigel Crisp, Former CEO of NHS & Member, House of Lords, believes that some of the challenges in the process of taking Telemedicine to higher levels could be :

ŸDoctors vs. Skilled Technician debate. There is still doubt that whether doctors will accept some of the work going to skilled technicians or nurses

ŸPatient un-receptability (example, one community not accepting vaccination because they think other community is trying to drug them)

ŸMarketing and taking the idea to bigger platforms ŸTelemedicine making real impact in big way is yet to come.

He suggested 3 point agenda for taking Telemedicine beyond pilot projects :

1 Visibility : Successful projects should be focused and their visibility should be increased with Government support. Government can do a lot of things which private sector or associations cannot do on their own.

2.Conducting research and evaluation : Medical research on how, and to what extent Telemedicine is helping should be done, similar to what New England Research Journal does. This field requires studies to substantiate the impact post pilot projects. A lot of companies will come up and sell different products and services but independent research can tell whether all those investments would be successful or not.

3. Quick win project : If Government can help embark on a short, one to two year project in a state, where any person can dial a number and call the health professional about his issues, the success of such a project would help the cause greatly in short term.

According to Dale Alverson, Immediate Past President, American Telemedicine Association; and Medical Director, Centre for Telehealth, University of New Mexico Health Sciences, concept of ‘Triple Aims’ needs to be applied to Telemedicine :

1. Access : The access to networks (broadband, telephone) is important for the delivery 2. Outcomes : Every new concept is as popular as its success. Telemedicine must improve the

state of healthcare and prove that with examples 3.Reduce cost : Telemedicine must reduce the cost of providing healthcare to the needy

According to him, fully integrated approach would help. Integration of various concepts and things such as EMR, ehealth, mHealth will help in the long term. The need of the hour is to focus on major issues and fill immediate gaps in the Telemedicine delivery eco-system. Telemedicine requires a combination of a top down and bottom up approach. It would require Government intervention, intervention of hospitals, patients, doctors, and technology. Public policy needs to be formed, keeping in mind how Telemedicine can make maximum impact. In the US, there is a taskforce, there is work going on to have EMRs of the entire population of patients, have guidelines/standards, have a health information exchange and Grant programs. Similar effort is required in all the countries to take Telemedicine beyond the pilot phase.

ŸToday, there are many applications in the market that enables healthcare service delivery, impart education, and enable preventive healthcare. However, medical practitioners, patients, normal people and other stakeholders need incentives to use these Telemedicine applications. A proper incentive



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system which benefits all involved parties is required :

Ÿ Healthcare service providers use different technologies and many times custom user interfaces. In order to motivate these service providers to come together on a single platform and share information with each other in order to create a unified healthcare system, it is highly important that these entities are properly incentivised to share the information. Differential pricing mechanism can be used in order to cover the cost of providing healthcare services. Rich people whether in villages or cities, can pay full amount for the healthcare service and the saved subsidy can be used to further subsidize services for poor ones.

Ÿ Critical drugs are unavailable in rural areas and some remote parts of the country. In order tocreate a robust supply chain that ensures continuous supply of medical drugs, an all connected system needs to be put in place. This system will include hospitals, patients, as well as pharma companies. The entities in this system need to be incentivised in order to have an interconnected flow of information that will enable them to share information among themselves.

Ÿ There are approximately 881 million mobile phones in India, which can be used for pushing as well as pulling information, among masses, about preventive healthcare, as well as other healthcare services. However, an incentive system must be put in place in order for the people on the ground level to use these services and provide or access health related information.

Ÿ Medical practitioners are often reluctant to use technology for providing healthcare service. This is so, because it requires extra efforts to familiarize themselves with these technologies. The United States has been experimenting with a scheme which provides doctors an extra compensation that uses technology for providing healthcare services. The same model can be experimented in India.


Ÿ People in rural areas are often impoverished to pay for any kind of medical insurance or enrol themselves for any kind of healthcare services. But these people can provide information regarding their immediate surroundings (using simple tools such as mobile messaging, etc.) which can be useful for mapping diseases on a national level, and enhancing preventive healthcare. These people need to be encouraged to participate and in return be compensated for their valuable service. Mobile currency or talk time can be offered to people on the ground in order to compensate them for their efforts. Telecom companies can be stakeholders as they can engage in a positive social cause while promoting themselves. This can also be undertaken as part of the CSR activities.

Ÿ The immediate benefit of Telemedicine is enjoyed by the patient who receives the service instantly and closer to home, but the institutions and organizations building the Telemedicine infrastructure and connecting all the other stakeholders benefit only at a later stage. These institutions need to be compensated in their early stages so that return on investment can be justified.

With its large medical and IT manpower and expertise in these areas, India holds great promise and has emerged as a leader in the field of Telemedicine.

“Telemedicine internships must be mandatory as a part of curriculum, and doctors in urban areas should be mandated to spend certain hours every week on teleconsultations in rural areas



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Ÿ Telemedicine: An Important Force in the Transformation of Healthcare, ITA, 2009

Ÿ Report on the second global survey on eHealth, WHO, 2010

Ÿ Towards the Development of an mHealth Strategy: A Literature Review, WHO

Ÿ Transforming through Innovation- Redefining Indian Healthcare through Advanced Informatics report, David Thomas

Ÿ E-health - drivers, applications, challenges ahead and strategies: a conceptual framework report, Indian Journal of Medical Informatics

Ÿ Current Telemedicine Infrastructure, Network, Applications in India report, S K Mishra, L S Sathyamurthy

Ÿ mHealth and Public Sector Reforms in India report, Dr. Tarun Seem, Director, NRHM Ministry of Health and Family Welfare

Ÿ Ministry of Health and Family Welfare, Government of India

Ÿ Telemedicine Opportunities and development in member states report, WHO, 2010

Ÿ Telecommunications for e-Health, ITU report 2011

Ÿ Scaling e-Health Services in step with ICT Transformation, ITU report

Ÿ Implementing e-Health in developing countries, ITU report

Ÿ Health unwired, PWC report, 2010Ÿ Global eHealth Atlas report, WHO, 2011Ÿ Global mHealth report, WHO, 2011Ÿ Current status of Telemedicine Network in India

and Future perspective report, S.K.MishraŸ The Current Status of eHealth Initiatives in India

report, Saroj Mishra, M.S., FACS K. GanapathyŸ Towards standards for management and

transmission of medical data in web technology report, Dr. Francesco Sicurello



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Ÿ Telehealth in India, ITU reportŸ Communication and Training for Healthcare

Worker publicationŸ Apollo Hospitals Ÿ Cisco Advances India Telemedicine ProgramŸ Care Hospitals Ÿ Nanavati HospitalŸ Centre for Health Market Innovations reportŸ WiMax services enhance teleservices

in India report Ÿ Emerging Trends in Healthcare –

KPMG Report 2011Ÿ IBEF Healthcare report 2010Ÿ Crisil Research Hospitals Annual Review

November, 2010Ÿ IDFC Securities Hospital Sector

November report, 2010Ÿ Current Telemedicine Infrastructure, Network,

Applications in India S K Mishra, L S Sathyamurthy

Ÿ A Telecommunication Network Architecture for Telemedicine in Bangladesh and Its Applicability report, M. Sanaullah

Ÿ Telemedicine Healing Touch Through Space report

Ÿ mHealth for Development, The Opportunity of Mobile Technology for Healthcare in the Developing World, United Nations report

Ÿ Narayana Nethralaya Ÿ mHealth Magazine, 2011Ÿ Telemedicine Society of India,

Telemedicon 2011Ÿ Gavlin Consulting 2011Ÿ Transforming Healthcare with mHealth

Solutions – 2011Ÿ The Opportunities, Efficiencies, and

ROI of Mobile TechnologyŸ Technology Coast Consulting

About Telemedicine Society of India (TSI)

TSI is a not-for-profit society formed in 2001 by senior scientists of Indian Space Research Organization (ISRO), senior doctors from various national level institutes & senior officials of the ministry of health & Ministry of Information Technology, Government of India. For the past ten years, TSI has done commendable work in promoting the practice of Telemedicine and mHealth, spreading awareness and updating the users, providers and patients on the benefits of using telehealth and mHealth in healthcare delivery.

Health & Medicine

Telehealth Report - India