Telemedicine The Possibility and Realities

 Prof. and Head of the Department
 Urology & Renal Transplantation
 Sri Ramachandra Medical College
 Chennai - 600116
 srmc69@eth.net

"We did not run fast enough to stay in the same place"
                                   - Lewis Carroll in Alice in Wonderland

In the history of mankind lucky are those who have witnessed a revolution that has changed the world they have lived in and created an air of excitement in their lives. The last century has been an exception as we have witnessed several such revolutions in our one lifetime and possibly will witness many more to come. Internet is often termed as the final frontier in the transition to the Information Age leaving behind the Industrial Age. The wonders of telecommunications and Information technology have freed the practice of medicine and Surgery from the constraints of space and time. Today we are standing at the threshold of a world of possibilities thrown up by technologies such as Virtual Reality, Cybersurgery, Micro - robotic Surgery and 3D image modeling.

The last twenty years has seen the transition from the "Golden age of Surgery" of the industrial age into another era of "Minimally invasive and non-invasive surgery" of the "Information Age". For those of us who have been part of this transition time, the years have been exciting However for some who have recently embraced the surgical-speciality and were champions of video "Nintendo Games" are likely to witness many more interesting and far reaching revolutions in this field. Ever since surgery evolved as a specialty, it has been recognized to be both an art and science but today technology has become the third dominant element of surgery. The information revolution stems from the ability to disseminate large quantities of the most current information in a systematic way to all who need to know. Health sciences are already emerging as the greatest beneficiary of this revolution with the de-coding of the human genome ahead of schedule and the new budding specialty of bio-informatics is already promising to write a different scripture for the healthcare industry and have the most far reaching impact on the health of mankind globally. 

Today in the year 2003, the future is already here and staring at us in many forms. Development in telecommunication, robotic and computer technology has already produced clinical devices and prototype systems for "laparoscopic surgery" and taken us into a futuristic surgical dimension of both learning and practice. As their utility and acceptance by the community increases, it will be imperative that the doctors of this millennium be familiar with this new field of medicine. To understand this new philosophy and paradigm shift, one has to first understand the fundamentals of how the computers of this information age are already shaping up the future of health care industry. In this new age, the entire foundation of practice of medicine will change. However, it is essential to embrace some amount of caution before becoming over-enthusiastic about any new technology; we as scientist should look at its merits and demerits before accepting this progress. There are already loud cries about the "dehumanization effect" this technology is bringing in. Medical Ethics may have to be re-written. It is possible that it may be too fast an adaptation for the human mind. The social code of conduct and changes may not be able to keep pace with the rapid advance of science and in the end, the decision to change may have to be left to the individuals and the society. 

TELEMEDICINE - CONCEPTS AND REQUIREMENTS 

The concept of delivering healthcare remotely is not new to clinicians. Graham Bell's invention of Telephone has helped Telemedicine exist in some nascent form since the last century. We in good faith are constantly giving advice to our patients over the telephone. Whether it is "Pop in a couple of Aspirin tablets" for headaches or "drink plenty of water" for stone disease. More serious Telemedicine has been available in some form for the past forty years and was necessitated due to the need to monitor astronauts in space. The current rapid advances in the frontiers of telecommunication and information technology gave birth to Telemedicine where medicine has merged inexplicitly with technology to benefit patients who does not have access to advanced health care. The Telemedicine Industry Report 2000 forecasts that the telemedicine industry will grow 40% annually over the next 10 years and it is predicted that by 2010 almost 15% of all healthcare services will be provided using telemedicine.

"Store and Forward" Telemedicine on Internet E-mail is the most popular and straightforward form of Internet use. Not surprisingly many patients find it convenient to consult their doctors and seek appointment using the e-mail format. This form of consultation is well suited for non-emergent situations and sometimes for second consultations. Consumers can store their medical records electronically including their ECGs and x-rays and transmit it if necessary to anyone, anywhere and at any time (www.medindia.net or www.mdconsult.com). 

On another site, offering "Transplantation Telemedicine" a patient with renal transplantation is able to keep in touch with their physician on the net and get advice according to the changes in their blood parameters. (www.mohanfoundation.org). If the blood results that are fed in are abnormal, (example potassium level of 6 mmol/l) the computer program flashes a message asking the patient to see their local doctor immediately. Areas of medicine that are benefiting using this type of technology include Teleradiology, telepathology and teledermatology. Some medical units use this type of telemedicine to follow-up of their patients who are remotely located. The above types of telemedicine has limitations as there is no direct visual contact between the patient and physician 

Active Server Pages or ASP - These types of pages are very popular on the health web-sites. Here a surfer is able to interact with the web-site pages and gets an answer to their question or problem instantly. For example, there are sites that will tell a viewer their ideal weight if they feed in height or will tell them their latest "International Prostate Symptom Score" (www.medindia.net) if relevant questions related to their symptoms are answered. The score is available in six Indian languages. Once the score is calculated by the program, it gives advice regarding the necessity or urgency to see their physician or urologist. Other sites today are offering to calculate one's risk for heart attack, colon cancer and many other similar ailment risks (www.msnbc.com).

1.  Telephone and Facsimile consultations
2.  "Store and forward" Type of telemedicine using Internet 
     facilities
3.  "Active server pages" on Internet offering answers to  
     medical questions
4.  Two-way online interactive Televideo and audio 
     conferencing 

Table.1 Forms of Telemedicine Practice

TELE-VIDEO CONFERENCING - "On-line" direct visual and audio consultations between physician and patients or between physician and physician or student is possible using video-conferencing and is the most serious type of telemedicine of this millennium.. A typical telemedicine setup for video-conference is depicted in Figure.1. 

Telepsychiatry is considered as a "grand-daddy" of interactive-video consultation applications. Many disciplines of medicine are now being established for this form of practice (Table.2) and are likely to lead to considerable cost-savings.

• Tele-Psychiatry consultations
• Tele-Radiology
• Tele-Dermatology
• Tele-ENT care
• Tele-Pathology
• Tele-Cardiology
• Tele-Home care
• Tele-Prison care
• Suitable for second opinions
• For follow-up of patients

a.  ISDN - 1 line - Gives 10 to 15 picture frames per second 
    (hence quality not good)
b.  ISDN - 3 lines - Ideal for video-conferencing
c.  Using Geo-stationary satellites 
d.  Through Internet - Need static IP address and at least a 
     512kbs bandwidth connectivity .