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Journal of the Academy of Hospital Administration

Telemedicine Essential Requisites for the New Millenium

Author(s): Shakti Gupta*, Sunil Kant **

Vol. 12, No. 1 (2000-01 - 2000-06)

Keywords : Telemedicine, Computers, Networking, Internet


The last decade has witnessed a revolutionary array in health care dimensions. Terms like 'Total Quality Management', 'ISO - 9000', 'Continuous Quality Management', 'Reengineering', Benchmarking, Accreditation, Information Technology and Telemedicine have embraced and got incorporated in the delivery of health care services. Globalisation, economic liberalisation, privatisation of health services coupled with patients enhanced awareness and expectations from providers of health care have made 'Quality' an inseparable part of the health care delivery system. To attain quality, accurate and timely information is essential. Telemedicine is thus becoming a strategic essential of a modern health care system1.

Telemedicine Defined:

Telemedicine is a system of health care delivery in which physicians examine distant patients through the use of telecommunications technology. The term "Telemedicine" is derived from the Greek "tele" meaning "at a distance", and from the Lain "mederi" meaning "healing". Telemedicine, thus, enable people in one geographical area to have access to highly trained medical specialists in another. This service is delivered either via two way interactive video or via two-way time delayed, store and forward multimedia electronic mail. Telemedicine is acquiring enhanced multidisciplinary and multifaceted roles. Initially the term was restricted as a means of providing medical services to remote locations through sophisticated telecommunications technology. It allowed physicians at leading hospitals worldwide to deliver a range of leading edge medical specialities to virtually every city in the world . Now the term telemedicine also encompasses other parameters like transfer of medical education information and has been defined as an enabling technology to facilitate the transfer of patient or educational information to another person or place.

Telemedicine Spectrum:

Driving Forces

The driving forces for Telemedicine advancement and adaption have been as follows:-

(a) Communications Infrastructure Development. There has been IT explosion with network development and increase bandwidth availability.

(b) Decreasing cost of data transmission.

(c) Scientific Advancement in digitalisation of medical and non medical requirement.

The world wide connectivity of the Internet, comparative low cost of operationality, user friendliness, and real time communication have aided the popularity and advancement of Information Technology.

(d) Societal Changes. There has been an enhanced awareness amongst health care seekers and providers for medical information and medical management.

A telemedicine system can be as simple as a computer hook-up or as advanced as "robotics-surgery" facility. Varied branches of medical specialities such as cardiology, pathology, neurology, psychiatry, dentistry, nursing, geriatrics, dermatology, ophthalmology, otolarynogology, endoscopy, emergency care, home health care and rural tele-medicine are at present in practice in telemedicine. The telemed specialists make either elective application for making diagnosis or tackle medical emergencies by inter-physician communication or by direct physician-patient contact3. Telemedicine facilitates multisite, multimedia (audio, video and data) medical information transmission. It presents a single integrated interface for scheduling, intimating, conducting and managing consultations. Tools may be provided to

  1. share images, patients records and supporting data.
  2. Transmit and store medical images and X - rays.
  3. Capture images in real time form through a video camera, digital medical instruments or high resolution still cameras.
  4. Store and forward single item or entire multimedia patient package (folder).
  5. Concurrently display patient data, audio/ video conference.
  6. Annotate findings and record transcripts ( test, audio or graphic.)
  7. It can incorporate built in security and encryption features.

The Spectrum of telemedicine is depicted in Fig 1

Advantages of Telemedicine :

  1. Before transferring serious patients to Central Hospital where much specialised treatment can be given, from the remote areas, medical staff at the hospital, through X-ray pictures etc can receive information in regard to the patient which in turn enable to prepare for the oncoming surgical operation etc.
  2. Unnecessary transfer of patients and doctors' visit can be saved by examining CT scan and X-ray pictures.
  3. For those medical staff, who reside in a remote Island and receive teleconsultations which in turn can render appropriate medical practices.

Applications of Telemedicine:

Potential Applications:

  1. Facilitate information exchange during care process where patient and healthcare provider or healthcare provider and experts, are separated by distance and time.
  2. Support more efficient administration of services and utilization of healthcare manpower resources (e.g. service center with pool of expertise to overcome shortage of resources.)
  3. Provide an effective and convenient means to support Continuing Medical Education for our healthcare professionals.

Specific applications:

  • Consultation between medical professionals.
  • Consultation between clinician and patient.
  • Investigations and treatment of patients.
  • Rehabilitative care and remote monitoring of patient conditions.
  • Paramedical care and investigation during emergency.
  • Surveillance care of elderly population.
  • Patient education for self - management by patient's family and home caregiver.

Telemedicine is not simply a mixing of telecommunication with medicine, but rather a system for delivering health care. As a system, it requires a shift in mindset and the ability to see new and more productive interrelationships among medical professionals, patients, insurers, policy makers, businesses and the community at large.

The applications of telemedicine in various disciplines :

1. Tele - Cardiology

This includes trans - telephonic electrocardoigraphy, echocardiography, tele - transfer of haemodyanamic, blood gas and bio - chemistry parameters for intensive cardiac care services.

2. Tele - Radiology

Development of filmless Direct Digital - Technology (DDT) for radiographs, CT scans, MRI and ultrasound pictures is the latest advancement in the field of Tele - Radiology. The main advantages are reduction in the processing transmission time of report and its receipt by the referring physician. It also facilitates expert opinion of radiologists to remote and for off places.

3. Tele - Pathology

These services have enhanced the ability to confer, educate and communicate to the referring physician. They provide a direct contact; the images can be stored permanently and are available for report consultation. They may also be sent to various experts at the same time who can make real time interaction amongst them solves.

4 . Trans-Telephonic Electro- Cardiographic Monitoring (TTEM)

In this the ECG is transmitted over a telephone line and recorded by cardio-beeper TTEM is of great utility for early diagnosis and management of IHD cases. Since the time delay between the onset of symptoms to accurate diagnosis and initiation of therapy is the most important determining factor for patient survival. Other uses include assessment of battery depletion in pacemakers of patient, to follow up patient with Automatic Implantable cardioverter Defibrillators, home rehabilitation programme after CABG (Coronary Artery Bypass Graft) surgery. TTEM also helps to avoid unnecessary hospital admission. TTEM is being successfully implemented in health care institution like Apollo.

The other disciplines where telemedicine has been successfully utilised are medical video conferencing, tele neurology.

Essential Requisites for Successful Implementation :

The essential requisites are as follows :

1. Convergent Medical Terminology

This is an enterprise vocabulary system that will enable clinical documentation, decision support and all the key clinical components to communicate with each other in the same language.


It offers the following advantages :

  1. More patient specific information will be available for decision support, outcome analysis and workflow management.
  2. Establish a national basis for longitudinal patient records.
  3. A higher degree of accuracy for comparing data and outcomes across healthcare organizations.
  4. Access to the right data at the right time will improve understanding and management of referral utilisation patterns.

2. Clinical Data Repository

This is a shared data repository that serves as the foundation for all clinical applications, such as the electronic medical record, disease management, results reporting, orders and in-box.


It has the following advantages :

  1. A fully integrated, patient - focused, clinical data set to support all care setting in the integrated delivery system.
  2. Enhanced ability to make evidence - based care decisions via continuous availability of data.

3. Population Care Registry

This is an online tool for proactively caring for health conditions ( eg diabetes, coronary artery disease, congestive heart failure, asthma and depression).

It highlights when patients are due for planned examination or screenings, enabling clinicians to practice more preventive care and highlight potential problems before they develop in to serious health conditions.

It will also enable more preventive care through the use of online health risk assessments.

Britain is to spend 1 million Sterling in the next 7 years to make all information in the National Health Service (NHS) accessible electronically. An electronic patient record for every person in the country will be available. They have envisaged that by 2005 general practitioners will be able to exchange patient records electronically. Clinicians will have 24 hours emergency care access to the records Confidential patient data will be protected by encryption technology.


The advantages are :

  1. Planned examinations or screenings.
  2. Improved patient outcomes.
  3. Increased patient satisfaction with thorough-ness of care.
  4. Reduced avoidable utilisation (eg hospitalisations, emergency department visits).

4. Clinical In -Box

This is an infrastructure and application to support communication between patients and providers, results reporting and e-mail. It provides alternative ways to meet patients needs other than an office visit.

It supports manual creation of messages using free text and standard templates message management within care teams, automated notification of messages, messages to associated areas, such as pharmacy and lab, reminders, alerts and messages tracking with audit trail, results reporting and e-mail.


Its advantages are :

  1. Improved patient / provider communications.
  2. Assurance that all messages are answered.
  3. Improved processing time for message handling.
  4. upport for providing effective ways to meet patient needs without an appointment. An important essential request is an increased awareness of the process amongst health care seekers and providers.

Recent Concepts in Telemedicne:

1. Wider Dimensions

Telemedicine is no longer restricted to only providing clinical consultations, now CMEs, conferencing medical information and other dimensions are in the ambit of telemedicine. Stanford University provides information on clinical administrative, research and other activities . Hospital in countries including S.E. Asia are providing, appointments, consultations through telemedicine. There are presently more than two hundred and fifty medical related websites5.

2. Recepient, Caregiver Friendly

Telemedicine provides benefits to all providers, sponsors and receivers of health care. The Britain - on - line project envisages that eventually all patients will obtain passwords to consult their own medical records.

3. Ethical Guidelines for Telemedicine

The World Medical Association is developing new ethical guidelines for the practice of telemedicine. According to the proposal. "The principles of medical ethics which are binding upon the profession shall also be followed in the practice of telemedicine. Normal roles of confidentiality and security also apply to telemedicine documentations. Storing or transmission methods may be used only where confidentiality and security can be guaranteed". The French - American proposal regarding telemedicine includes thirteen recommenda-tions for physicians. These include that physicians are free and independent to choose or reject the use of telemedicine, when possible, physician should obtain patient consent when seeking an expert opinion of a colleague from a distance, physicians are responsible for safety and quality of treatment provided by nonphysician personnel, physicians seeking an opinion remain responsible for the diagnosis of the patient, and physicians should remain fully committed to professional confidentiality and should be accountable for any information they disclose.

Feasibility of Telemedicine in Developing Countries :

The various barriers in the delivery of specialised health care in India are.

  • Distance
  • Roads
  • Travel Cost
  • Lack of Public Transportation
  • Travel Time
  • Waiting Time
  • Cultural Time
  • Economic Barriers
  • Non availability of Specialists

India sub continent has many peculiarities in addition to having a very high population. It has diverse geographic areas, different climatic conditions and a large number of ethnic and groups with varied culture. Be it the desserts of Rajasthan, rugged terrains of Himalayas, the peninsular seashore or the wide forests of North East, no wonder these peculiarities throw tremendous challenges to the health care delivery system.

The basic health care delivery unit is the primary center which is the hub of multi sectorial health care activities. Country has around 21,854 primary health centers supports by 132,730 sub-centers. The referral and research services to these centers are provided by a network of 115 medical colleges and district level hospitals. The pattern of the hospitals in India is as under :

Types of hospitals Hospitals Beds % of total beds
Govt. Hospitals 4,379 415,628 67.10
Local Bodies Hospitals 353 23,419 3.78
Private and Voluntary Organisation 6,522 180,386 29.12
Total 11.254   619,433

Infection, infestation and other tropical disease and their complications constitute the major cause of morbidity in the population. Disease emerging out of changing life style like Coronary artery disease, rates vary rapidly. Rapid industrialisation and urbanisation which are common eventualities of developement have contributed significantly to accelerate accidents emergency situations and disasters. India spends around 1.5 to 2% of its GNP on health. Considerable expenditure is incurred in the training of doctors, specialists and super specialists but the benefits of the expenditure is unable to reach the masses in distant areas. This is merely because due to better quality of life and good infrastructure available limited cities have a concentration of specialists and super specialists.

In a developing economy, it seems evident that secondary and tertiary level care centers with complete trained manpower cannot be provided at the door step of the people. Health being a purely state subject does not generate adequate revenue to sustain itself. The health insurance due to certain difficulties is unable to carve a niche into the health care system. Here comes the question how to bridge this gap between the primary physician, specialist and the patient.

There has been rapid advancement in the field of science and technology in the last two decades and the lot of credit can be attributed to the liberal economy policies of the succeeding government. It has been observed that the telecommunication network and the audio visual media has played a key role in mass education campaigns. Now the Govt of India has decided to completely revamp the existing information technology and make it state of the art by the year 2000. The government is committed to ensure advanced communication facilities like the Net and E-mail at every trunk booths. For this, task force has been constituted to look into the HRD aspects of this ambitions plan. Use of satellites, cables and fibre optics is going to be the very common happening in the near future.

The vision of medical providers accessing computer consultation network and world wide database of text and images is being realised. Telemedicine allows instant international consultations and access to vast reservoir of experiences of others. It is more applicable to developing countries where extensive areas are remote and not satisfactorily connected by telecommunications.

Telemedicine has the potential to provide routine and specialist services to both patients and physicians in rural areas. The process is particularly valuable in medical emergencies. Referred patients may become further sick if they do not receive even basic initial resuscitative support. Another advantage of telemedicine is that patients with non serious ailments are unnecessary transferred as emergency cases. The World Medical Association has commented "Previously reserved to developed countries where regional planning problems were the most severe, telemedicine is today bound to develop not only through the establishment of many regional networks within countries with high medical population densities but also between those developed countries and developing countries"4.

Thus telemedicine is applicable to the developing countries. The existing information technology infrastructure with augmentation will enable it to be adopted in developing countries.

Resource crunch and concentration of specialists centres in the urban area , are other factors existing in developing countries which makes telemedicine applicable and potentially output oriented.

There are few question which bother Indian Physicians before they accept telemedicine as a means of health care delivery.

(a) Will the practice of medicine become more equipment oriented rather than depending upon experience and scientific clinical judgement of the physician. ?

(b) The primary physician have a feeling that they will all be relegated to the second position by the patient.

(c) The private sector may look for big money and start malpractice.

(d) Before the onset, Telemedicine Act has to be formulated passed by the parliament to protect the right of providers and the patients so that the legal liabilities and implications can be clarified. The Consumer Protection Act (CPA) which has brought medical professional into its ambit, is also a deterrent in absence of clear cut legislation on Telemedicine e.g. if transmission of data gets corrupted or stopped from a patients to a telemedicine command center, who will bear the legal liability? Is it the doctor or the telecom service provider? There is also a vital question amongst the Indians regarding reliability, adequacy and accuracy of electronically transmitted data for making a correct diagnosis and for providing expert advice to a patient by a physician at a distance. Can data replace actual examination?

Therefore, the country has first to assess the reliability of the system and impart training to the user and the patients so awareness is generated on this issue. The Government has to then enact necessary legislation which could be finally converted into a health policy on Telemedicine.

Telemedicine: The Future:

Telemedicine is a communication system, a network of electronic travel that connects primary care physicians, specialists and patients. As a system, it challenges the leaders of hospital, clinics, nursing homes, mental health facilities and medical schools to rethink the way they provide a complex array of health services, functioning less as isolated entities and more as part of greater whole.


Telemedicine is more than just tele-communication. Telemedicine holds the promise of

provided - by assuring medical access to remote locations, by reducing health care costs and by enhancing medical dialogue. Knowledge is the connection in telemedicine and it supports the increasing emphasis in health care on a continuous of care from cradle to grave and across a spectrum of service providers6. It offers benefit to the managers, providers and receivers of health care. It is a systematic consistent technological process and not just extraneous in healthcare. The prerequisite in embarking on the arduous road of implementation is the commitment at all levels of management. Telemedicine is no longer just a strategy, it is a necessity.


  1. Lele RD; Computers in Medicine, Tata Mc Graw - Hill Publishing Company Ltd, New Delhi, 1997. P 112 - 114.
  2. Naval K; Internet for Doctors, Vikas Publishing House Pt Ltd, 1998.P 88-90.
  3. Rissam H. S, Kishore S. N. Trehan, Telemedicine - A Revolution on the Horizon, J K Science Journal of Medical Education and Research, Jun 1999; 34 - 37.
  4. Asian Hospitals; Health Asia Communications Ltd, Hongkong, May / June 94. P 26.
  5. Tanenbaum.V; Computer Networks, Prentice Hall of India, 1996. P 17 - 22.
  6. Leslie J; Global Telemedicine Strategies, Symposium document - HEAT - 97, AIIMS, New Delhi, P - 25.

* Additional Professor, Hospital Administration, AIIMS, New Delhi,
* * MO (HS), Military Hospital, Dehra Dun

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