"Low tech" telecommunication tools include:

· Telephones

· Facsimile machines

· Video cameras and monitors

· Overnight courier services

"High tech" telecommunication tools include:

· Computers

· Digital imagery

· Internet

Using any one or a combination of these tools to facilitate health care that is of better quality (relative to existing norms), or which is delivered in a more efficient manner, constitutes Telemedicine.

While Telemedicine is the use of electronic information and communications technologies to provide and support health care when distance separates the participants, Telehealth further broadens the scope of the Telemedicine Infrastructure to provide additional features and services. Telehealth, by definition, is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.

A working Telemedicine model consists of:

a) Telemedicine Speciality Center(TSC)

b) Telemedicine Consulting Centre (TCC)

Telemedicine Super Speciality End

Telemedicine Specialty Centre is a site, where the specialist is present. He can interact with the patient present in the remote site and view his reports and monitor his progress.

Telemedicine Consulting Centre

Telemedicine Consulting Centre is the site where the patient is present. Here the equipment required for scanning /converting, transformation, communicating for medical information of the patient is present.

Telemedicine – Process Overview

The Process Overview above indicates the connectivity between a Telemedicine Consulting Centre (TCC) and a Telemedicine Speciality Centre (TSC). A Telemedicine Consulting Centre has various medical equipment (CT Scan, Color Doppler etc.) that have been interfaced with the Telemedicine software whereby the specialist at the Telemedicine Speciality Centre will be able to view the live medical images of the patient. The Consulting Centre has a high end Scanner for scanning X-rays and transmitting to the Speciality Centre, a web camera for net meetings, and videoconferencing equipment to videoconference with the specialist at the Speciality Centre. The connectivity from the Telemedicine Consulting Centre to the Telemedicine Speciality Centre can be through either one of the channels:ISDN, VSAT or Leased line.

Consider a typical Telemedicine interaction. The Patient goes to a Doctor, who after examination of the patient's file feels the need for a second opinion. The Doctor then consolidates the relevant clinical data into the patient's Electronic Medical Record (EMR) and then seeks an opinion of the Specialist using TeleConsultation. A connection to the Specialists Workstation is initiated, and the Patient's data uploaded. The Specialist then examines the data to make a diagnosis, to provide advice and suggest a course of action. The two Doctors get on to a videoconference to jointly arrive at the diagnosis and the course of

treatment. This advice is then transmitted back to the presenting Doctor who takes appropriate action.

This essentially avoided the patient discomfort of having to travel to the Specialist's office/ clinic without the Specialist having to visit the patient; this is especially important if the patient is in trauma. The right care was provided at the right place at the right time with minimal discomfort to all concerned. This sort of interaction is quite possible and is becoming quite common. ATNF integrated Telemedicine Solution, Medintegra, provides an Integrated Solution to make such interactions possible and more. Medintegra can be used to provide Tele-medicine Consultation for various fields of medicine - TeleRadiology, TeleCardiology,

On closer examination of the interaction, we find that there are two main aspects viz. making & managing the EMR and the actual TeleConsultation. Let us see how Medintegra facilitates these two aspects.

Usually the Patient Record (PR) is available in the hardcopy form (papers, celluloid films, ECG strips, etc.). Medintegra allows the Doctor to quickly put these together into the patients EMR and classify them. Data of various types like celluloid films, hardcopies, can be scanned in; ECGs, video-clips of endoscopies, angiographies, etc. can be made a part of the EMR (using direct interface to the devices), as can be audio-clips of electronic stethoscopes, dictations, etc. All such documents and images are stored in an encrypted form.

Once the EMR is consolidated, the Physician can quickly navigate through the EMR.

Medintegra provides means to view data in a classified form, with a tab for every type of data present eg. X-ray, ECG, Reports, Advice, etc. Medintegra also provides a Catalogue view that lists the various documents, images, etc. in the EMR with a short summary.

Medintegra equips the physician with a rich toolset to examine different data. It supports tools to pan, zoom, rotate, mark Regions of Interest (ROI) and annotate the data. Extensive Image Processing features are also provided.

Salient features of MedIntegra

• Consolidated EMR

• Authenticated access to EMR

• Easy to install, configure and use

• Comprehensive suite of tools

• well documented with easy to follow instructions

• Optimal Bandwidth utilization reduces cost of ownership

• Open Architecture

• Supports hybrid model of 'Store & forward and on-line Telemedicine'

• Industry Standards Compliant

• Interfaces with Industry Standard devices like Scanners, Camera, etc.

• Customisation support provided

Using Medintegra Software user -friendly interface, the Physician can also quickly add notes on the patient's progress, can create reports, advice, etc.

To seek the opinion of a Specialist- using Tele-Consultation, the Doctor can connect to the Specialist's PC from within Medintera Software. The presenting Physician uploads the relevant portions of the EMR to the Specialist PC. They can exchange Text messages to confer about aspects that are not brought out by the presented EMR. They can even get into a Videoconference.

The Advice, Reports, etc. that are the outcomes of the Tele-Consultation are sent back to the Presenting Doctor, to print and pass on to the Patient.

There are times when the Specialist would work alone, Medintegra also provides for offline editing of the EMR and subsequent data upload to the peer.

For connectivity, Medintegra uses any existing connectivity means that support TCP/IP protocol such as Dial up connectivity over telephone lines (POTS) or ISDN, etc.

For videoconferencing, Medintegra interfaces with any standard videoconferencing equipment that supports MS NetMeeting 3.0.

Medintegra can interface with a range of equipment, providing users the freedom to choose the best-suited option for their requirements. ATNF helps in evaluating specific clinical requirements and recommends suitable equipment.

Apart from the features of the standard version of Medintera Software, the following is an indicative list highlighting the range of customisations:

• DICOM support

• Support for specific HL7 messaging.

• Customized generation and printing of forms that include various parameters, reports, etc.

• Specific authentication support including Smart cards, Biometrics, etc.

• Integration with existing HIS, PACS or other Clinical Support System.

• Interface with various specialty devices.

Medintegra requires a Pentium II 350MHz or better with Multimedia capabilities running MS Win98/ Win2000, with 64MB RAM or more with Minimum 500MB free disk space, a 17" SVGA Monitor, a POTS/ ISDN modem and a TWAIN compliant scanner with backlighting arrangement. Video capture card and video-conferencing equipment are highly recommended.

Components for a working model of Telemedicine

For a working model of Telemedicine, following are the components that needs to be interfaced

a) Hardware

b) Video Conferencing Equipment

c) Software

d) Communication channel

Hardware

Hardware for a typical Telemedicine set up consists of the following:

· Computer with Web Camera and 17” Monitor

· Frame Grabber/Ethernet Card

· Terminal Adapter

· Laser Printer

· Scanner

Video Conferencing Equipment

This allows the specialist to view patient/ treating doctor on other side. This can be desktop-based (low cost) but the preferred variety is a full-fledged TV-based system on both sides with a high-resolution camera. This is needed because the diagnostic images need to be clearly viewed on the specialist side.

Software

Software consists of the following two:

Telemedicine Consulting Software for the Consulting Centre:

· Allows capture of all patient EMR (Electronic Medical Record) data such as Patient History, Diagnosis, Vital signs, Treatment Plan, Surgeries, Investigations etc

· Allows scheduling of Telemed appointment with the specialist end

· Allows facility to transfer Medical Records to other side

Telemedicine Specialty Software for the Specialty Centre:

· Allows confirmation of Telemed appointments

· Allows download of EMR sent from Consulting Centre. Also provides flexibility in viewing diagnostic data (eg. X-rays, Ultrasound images can be seen)

· Allows live view of CT-Scans, Dopplers/ Ultrasounds via Video Conferencing for the specialist doctor

· Allows specialist doctor to send his consultation comments to the patient side

Communication Channels

The communication channels that are popularly used for Telemedicine are ISDN (Integrates Services Digital Network) and VSAT (Very Small Aperture Terminal).

· ISDN: ISDN stands for Integrated Services Digital Network. "Integrated Services" refers to ISDN's ability to deliver two simultaneous connections, in any combination of data, voice, video, and fax, over a single line. Multiple devices can be attached to the line, and used as needed. The "Digital" in ISDN refers to its purely digital transmission, as opposed to the analog transmission of plain old telephone service. When you connect with ISDN, there is no analog conversion. ISDN transmits data digitally, resulting in a very clear transmission quality. There is none of the static and noise of analog transmissions that can slow transmission speed.

· VSAT: VSAT stands for Very Small Aperture Terminal. It is a satellite communications system that serves home and business users. VSAT handles data, voice, and video signals. The advantage of VSAT is that companies can have total control of their own communication system without depending on other companies. Users also get higher speed reception than if using ordinary telephone service or ISDN.