What is Telemedicine or Telehealth?

Tele ~ distance medicine/ health is the use of information and communication technologies (ICTs) to deliver health services where there is physical separation between care providers and/or the recipients over both long and short distances. It is about transmitting voice, data, images, and information rather than moving care recipients, health professionals, or educators. It encompasses preventive as well as curative aspects of healthcare services for recipients. The interactions can be between care recipient(s), care providers or educators, and lately also computerized devices—standalone, as well as working through a mobile.

 

Internet use, though widespread by the turn of the century, impacted telehealth much later as the initial systems required higher bandwidth than what was initially available. Among the earliest to benefit were specialities dependent on the interpretation of audio or images, either still or moving (video). Examples of the former were patient conversations, heart sounds, and speech therapy, while the latter included dermatology, cardiology (ECG, echo, and angiograms), ophthalmology, and pathology; a third group was if care could be administered through video conference (psychiatry). Special tools to enable transfer emerged, for example, tele-stethoscope and tele-ECG, and for telepathology, specialized microscopes exist wherein the movement of the slide viewer could be remotely controlled, as well as zoomed in on a real-time basis.

 

India has been an early leader in telecare among the developing countries. The need was emphasized by a large rural population, between 60% and 70% of the total, where even the few officially posted doctors would rarely be present on duty.

 

Almost all early deployments of telemedicine were large undertakings as there was a requirement of special staff and organizational changes. Usage of existing computing devices—belonging to patient or physician—helped bring down costs, besides being easy to use, as little further special training was required.

 

Telemedicine 2.0 was a relatively late beneficiary of this information explosion. Internet protocols allowed support for practically all information and traffic needed for telemedicine, including the following:

 

·        patient education (text, images, and video)

·        medical images such as X-rays and scans (DICOM image standards)

·        real-time audio and video consultation

·        vital signs and other body measurements (ECG, temperature, etc.)

 

Types of telecare

 

Let us begin by classifying the various methods of administering remote care. The first two are traditional; the latter ones came up with advancing technology. Currently a hybrid of almost all types is used:

 

1.     Real time or synchronous—here, information or data is transferred live. Video conferencing between a patient and the healthcare provider is the prime example. Others include live viewing of ultrasounds or angiograms as they are taking place, streaming of procedures from the OR, or of heart sounds using a tele-stethoscope. This is a convenient and easy form of telemedicine but requires high bandwidth, constant connectivity, and investment in related hardware.

2.     Store and forward (S&F) or asynchronous—information is recorded and transferred. It can be stored locally or in a server depending on when connectivity becomes available. Viewing, comments, and even incorporation of the data into a different server can occur at the convenience of the other participants of the telehealth stream. It is less dependent on constant connectivity but more complicated to administer. Choice of software and interconnectivity standards has a greater role—as interpretations may differ.

3.     Telemonitoring or remote monitoring—medical devices record and process personal information and transmit continuously (real time) or in a processed summary form (asynchronously) to the clinician. Examples are home care devices for old age and infirm as well as tele-ICU.

4.     Mobile health or mHealth is a special form of Digital Health. Smart mobiles have computing power and connectivity access better than specialized telemedicine systems of the past. They are inexpensive, have inbuilt audio and video, are flexible to allow both real time, and store and forward transmission as well as viewing from almost anywhere. Telemonitoring through inbuilt or even add-on sensors allows a single device to be a complete telehealth solution for a range of different problems. Many specialized applications or apps can directly inform the patient about their health status.

 

The process (how)

 

A sample flow chart is provided in the Figure below on how a telecare provider can do the coordination. The telecare administrator can be the healthcare provider himself, an outsourced agency, or directly operated by the government or insurance provider.

 

 

 

The list of factors for the development of telehealth services is not complete, but the factors earlier are among the most important factors. What is undoubtedly important for this development is that technology is playing a vital role in healthcare disruptions in general.

 

Definitions of EMR and EHR

 

Electronic medical record (EMR): According to Pramod David Jacob (dWise Healthcare IT Solutions, Banglore, India) an electronic record of healthcare information of an individual that is created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.

 

Electronic health record (EHR): An electronic record of healthcare information of an individual that conforms to recommended interoperability standards for HIT and that are created, managed, and consulted by authorized clinicians and staff across multiple healthcare organizations. It represents the concept of a longitudinal health record of the individual.

 

Basically, an EHR collates multiple EMRs across multiple healthcare organizations into a single comprehensive longitudinal or lifetime record for an individual patient. For this to materialize, multiple EMRs need to be capable of exchanging data with each other, a term called interoperability. Interoperability is obtained through following certain standardized coding.

 

How to ensure effective communication?

 

Effective telehealth requires a persons’ absence physically to be replaced by an effective form of tele to allow the healthcare interaction to proceed smoothly. Human-to-human communication depends on voice along with gestures of the hand, face, and to a lesser extent even other parts of the body like shrugging of shoulders or rolling up of eyes.

 

Tele is electronic communication beyond visible or hearing range. Telecommunication has constraints, which go beyond the technology, that is, a message may not be created, be incomplete, may not have been sent, not have been received, may have inadequate compliance to standards, and so on.

 

All forms of electronic communication, whether or not concerning telehealth, depend on a certain level of basics like input and output. Proper input is the first step of data creation. The same can be transmitted only if relevant data exist, else the adage garbage in garbage out or GIGO applies.

 

Video conferencing (VC)

 

A video conference is a two-point or multipoint communication tool where face-to-face live communication takes place using multimedia. It utilizes audio and video inputs that are uploaded and downloaded at the requisite ends in a seamless manner. Older telemedicine systems used a camera with an inbuilt communication methodology. Sophisticated systems exist, like the camera focusing, and turn itself toward the speaker, automatic mixing into multipoint screens.

 

Platforms for collaborative process

 

Arindam Basu (School of Health Sciences, University of Canterbury, Christchurch, New Zealand) described collaborative process as:

 

L is a 50-year-old non-smoker male with the history of hypertension controlled with ACE inhibitors. He is otherwise healthy and works as a manager of a private company. In December, he was spending an end of-the-year weekend with his family at a resort located 60 km south of Kolkata, the nearest large city. The resort management employed a newly qualified medical doctor as their medical officer. On Sunday at midnight, L suddenly started bleeding from his nose (“epistaxis”). The doctor on the house attended him but found it difficult to control the bleeding; he wanted to pack sterile gauze inside L’s nasal cavity to control the bleeding but was not sure how to do so. The doctor accessed an online medical group that he subscribed to, and with the help of an ENT surgeon in the group, he managed to insert a nasal pack and discussed subsequent management. The ENT surgeon who was available online helped the local doctor to control L’s epistaxis successfully and detailed to him the subsequent management. The next morning, L left the resort and attended an ENT outpatient clinic in Kolkata for further assessment.

 

Worldwide, an estimated 17 per 10,000 people attend emergency rooms or primary care doctors with nosebleed. The case describes a situation where a medical doctor delivers face-to-face care for a patient’ but uses elements of distance-based care: the patient (“L”), the primary care doctor, and the ENT specialist (“remote specialist”) who advised the primary care doctor (“local doctor”) were geographically separated, but the care was delivered on time. This was possible because the local doctor collaborated with a remote specialist to deliver care. Thus, part of the care was distance based and was Internet mediated. Such delivery of care is an example where providers, patients, and payers come together either just in time and collaborate or forge “participatory health care.”

 

Telehealth platforms

 

According to Magdala de Araújo Novaes Telehealth platforms are digital environments that allow health professionals to interact with each other and with their patients to promote patient care, education, and health research and to support health-care management. Unlike open social networks, these platforms are environments designed to meet the specific needs of telehealth services; restrict access to managers, health professionals, and patients; and must comply with quality and safety standards under current policies in each country. Therefore, such platforms are secure and evidence-based networks specifically tailored for the care of individual or groups of patients.

 

In teleconsulting for second opinions or for soliciting expert opinion, a telehealth platform is used solely for health professionals. In other situations, the platforms are open to be used by both the providers and the patient. In such situations the provider is responsible for conducting the assessment, guiding the patient, analyzing data collected from connected devices, and where necessary interacting with other specialists to manage the patient. In case of emergencies a telehealth platform can be used to provide professional “lifeguard” resources to enable care with specialist support by sharing data, images, video, and audio. In primary care, teleconsulting is frequently used by doctors to discuss diagnostic hypotheses, plan treatment, or triage the need for referral to another specialist in the referral network.

 

 

 

 

Telehealth services and software platforms

 

Telehealth services and software platforms provide a channel of communication among patients and doctors via video calls using multiple types of devices. Some platforms may provide inter-health-care integration services to consult and update clinical records from patients under treatment. Telehealth platforms can include workflow management (for managing the activities of the medical staff) and billing integration services.

 

Computer assisted care

 

Changes in knowledge and advances have made efficient and up-to date management of clinical problems a clinician faces challenging and possibly, beyond the learning capability of any individual. By 2020, it is estimated that knowledge about the body, health, and health care is projected to double every 73 days. Computer-based processing allows not only information transfer (telehealth) but also the process of generation of knowledge and wisdom—referred to as artificial intelligence (AI). There are many advanced sensors that extend the traditional five senses, which help in diagnosis and treatment. These can not only assist, but also may sometimes replace the care provider.

 

Identification of the problem is considered the first and most important step towards solving the problem. Traditionally, medical students are taught that 90% of the diagnosis is achievable through history and examination. Investigations and radiology have made diagnosis easier and also increased the possibility of it becoming more automated.

 

Diagnosis is considered an art and involves deductive capability of processing various inputs from a myriad of presenting complaints, findings, investigation reports, radiology, and other inputs into a final list or sometimes, even a single one (loosely referred to as “I’m feeling lucky”) final conclusion. All five senses traditionally used to be employed—for instance, tasting urine for sweetness of sugar—was conducted to diagnose diabetes in the 19th century. Traditionally, clinical methods are drilled into the clinician’s brain through years of training, observation, systematic studying, and experience gained through examination of patients seen in the past. Computer systems can do similar processing with some differences.

 

 

Telehealth project example

 

The actual project was divided in two main parts—a and b in the succeeding texts—while the remaining are essential add-on components:

 

a.      Teleconsultation services: A patient may call from any location using a phone (landline or handheld) by dialling a three-digit number to receive immediate advice on call. The doctors may be able to prescribe over-the-counter (OTC) drugs based on the symptoms detailed by the patient in accordance with the prevailing laws. The details of medicine shall be sent via SMS (to the patient), and the electronic prescription shall be sent via email to the patient and nearest public health facility. Further, some of the cases may be referred to the nearest PHC/CHC/district hospital, as per requirement of physical examination, conducting diagnostic tests and/or requiring specific medicines. In such cases of referral, the capability of sharing the information with the designated facility is essential.

b.     Video consultation services and patient nodes: Video consultation services shall be provided to the patients who are referred for video consultation services by government doctors at CHCs where patient nodes are setup. The service provider for video consultation services shall be responsible for scheduling an appointment for forwarded cases/referred patients by the doctors at the CHCs/authority for video consultation services. The video consultation service providers shall establish dedicated command center(s) anywhere in India for this project. The command center(s) shall have specialist doctors for conducting video consultation with the patients.

c.      Electronic medical record (EMR): For every patient, medical history and detailed records of consultations shall be maintained in the EMR system, which must capture mandatory fields and should have the ability to interact/integrate with other stakeholders/service providers for services like teleconsultation services or call center (health helpline) for telemedicine project, diagnostic centers, medicine dispensation centers/units, and central patient portal. The integration shall be done on a real-time basis.

d.     Consolidated MIS record: This shall have all the data gathered/saved/recorded/updated including details of any vitals/diagnostic tests.

e.      Central patient portal: It has to capture all patient-related information and to have a common platform for all related services.

f.      Central database and hosting server: For all of the above, it has to be expandable to cater to future demand.

 

 

FOR EACH REMOTE END
CAPEX (capital expenditure)
Patient end	Description
Preliminary location visit
General	Project management
Computer hardware	Printer with computer Web camera

 

 

 

 

FOR EACH REMOTE END—CONT’D

 

CAPEX (capital expenditure)
Patient end	Description
Telemedicine kit                     General equipment	Digitizer/scanner for digital transmission of X-ray/CT scan/MRI Audio-video facility This may constitute individual components or a single combined kit Digital thermometer Glucometer Pulse oximeter BP instrument Height stand Digital ECG Digital stethoscope Weighing scale Fetal heart monitor Pediatric weighing scale Dermatoscope Stools and chairs Examination bed Work desk

 

OPEX (operating expenditure)
Software Manpower (salaries)     Misc running costs	Client end Staff-ANM Staff-technician Project managers/Misc Stationery and other day to day consumables
Administration Insurance Command center Preliminary location visit	Lab reagents Connectivity Water and electricity Glucometer strips Hardware maintenance and replacement     Only one controlling entire project

 

EXPERT END (ONLY 1)

CAPEX (capital expenditure)
Furniture and fixtures Computer hardware General and Misc Software OPEX Specialists Connectivity Rent and running costs Other costs Training content Training camps Liaison with govt Project office Project team Team travel and other expenses Project administration Project travel Server/AWS service Database	Establishment cost, furniture, assets EMR (server end)   13 in number for 4–8 h per day   Stationery, water, others

The OPEX component can be used as a template for daily bookkeeping and items like interest added to create consolidated monthly reports.

 

Backup systems

 

Emergencies can occur anytime. In a telecare project, these problems are likely to be accentuated because of distance and relative lack of control of local developments. Avenues for correction and redressal are far more difficult but need serious attention. The problem gets accentuated with the lack of standard operating procedures (SOPs) and trained personnel. The Internet based resources are constant help, so training on how to use online search engines and online support systems are key to success.

 

Training requirements of a digital health assistant

 

Learning objectives

 

1.     To be able to operate telemedicine system located at telecenter.

2.     To be able to plan and organize telemedicine consultation sessions.

3.     To be able to enhance people-related skills such as communications with village people and with the consulting doctor.

4.     To be able to gain basic knowledge of community health emergencies for early reporting.

5.     To be able to maintain accounts related to the use of telemedicine system.

 

From a rural area perspective, the main requirement would be health data entry operators or Scribes for short. These personnel would digitize health information into an EHR, facilitate video consults, and also deliver healthcare, under online support and guidance from the clinicians. Required skills include knowledge about how IT systems work, validation checks and problems of auto correction, besides troubleshooting network errors. These would be an added resource, beyond knowledge of the disease set that they are supposed to handle and the associated health terms. Knowledge of coding, that is, entry of structured data using standards like ICD and SNOMED, would make it complete, but is not essential. Here, AI would ease adoption, but as of now, personalized care and human-to-human interaction are important components; just like in flight, a pilotless aircraft so far is not used to carry personnel.

 

An example would be the training program for personnel working in remote areas for projects run by SATHI. In the same, formal classroom training was organized at the central place in small batches of 15–20 persons and followed up with continuing education, online and offline through the telemedicine system itself or through internet. The initial training, even though classroom based, had content which made it participatory, interactive, full of practical exercises and games.

 

Learning is eased if the trainees work within the same system and use the same software and connectivity as in the planned project. On-the-job training can and should continue. A help module has to be incorporated in the telemedicine software. This should include animated illustrations, games, and demonstration of all the key processes involved in operating the telemedicine system, organizing telemedicine consultation sessions (TCS), managing the telemedicine center, and interacting with the patients or the community at large.

 

Training needs to be done on actual patients or health service seekers in the remote area. In the process of consultations, they will be the “learning materials.” A provision of capturing the consultation process on video and reusing the same allows greater discussions or analysis.

 

S u g g e s t e d c u r r i c u l u m ( C u r t s e y S ATHI) 1. Introduction to telemedicine • What is telemedicine • Evolution of telemedicine • Advantages and disadvantages of telemedicine • Future of telemedicine 2. Operating telemedicine system • What is a telemedicine system • Hardware and software and accessories • Connectivity • How to operate the telemedicine system • Do’s and don’ts • Troubleshooting 3. Planning and organization of telemedicine consultation session (TCS) • What is telemedicine session • Prerequisites for TCS • Fixed day strategy • Planning sessions and preparing service schedule • EMR • Individual and group session • Online and offline consultation • Facilitating telemedicine consultation session • Counselling patients 4. Communicating with village people and doctor 5. Community health 6. Maintenance of accounts 7. Special programs catering to the unique needs of the current project

 

We endeavour to offer world-class Remote based Medical Opinion services and assistance in accessing follow-up healthcare services and support, when needed. Individually and collectively, we are committed to do all that it takes to allay your health-related fears, anxieties and concerns. We look forward to empower you and/or your caregivers to take charge of or become hands-on, well-informed person in making informed healthcare decisions even while relying on your existing healthcare providers for your medical treatment/surgery or day-to-day care.

Second Opinion in Surgery

— by Dr.Guriqbal Singh Jaiya on 1st Feb, 2021

 

Second opinions are an important part of the process of informed consent and decision-making especially when a major decision has to be made by the patient or by his loved ones who may have the responsibility to take the decision or assist in making it by the patient.

Often surgery is not the only option in a particular illness. Even when surgery is the only option, the timing and type of surgery may have many options. Different surgical options may have different costs, risks, benefits and aftercare requirements. The needs, concerns and expectations of the patient and caregivers often also impact a patient’s decision about whether, if, when and which type of surgery be undertaken. Different doctors often have varying and conflicting viewpoints about how a particular medical problem should be managed, whether through surgery or less invasive treatment means.

One surgeon may prefer to take a “wait and watch” approach by asking to take certain lifestyle measures and/or medications before recommending surgery, while another may recommend early surgery to avoid complications requiring emergency surgery. Another surgeon might consider the risk of waiting to be too high as the patient may not remain fit to have the surgery due to progression of the illness beyond a particular threshold. In some cases, very different surgical techniques may be viable options for the same patient. The competence and experience of a surgeon might make a big difference in what the surgeon is willing to do or the risk a patient is willing to take by getting operated by a particular surgeon or in a particular country, city or hospital. The track record of a surgeon and his team matters. Medicine does not always provide a simple answer which cannot be questioned, and of course physicians are human, and therefore capable of making mistakes despite their best efforts.

In some cases, there are no symptoms or atypical symptoms which may suggest that the problem is not surgical when actually it is. For example, Hyperparathyroidism is often diagnosed before signs or symptoms of the disorder are apparent. When symptoms do occur, they’re the result of damage or dysfunction in other organs or tissues due to high calcium levels in the blood and urine or too little calcium in bones. Symptoms may be so mild and nonspecific that they don’t seem related to parathyroid function, or they may be severe. Hyperparathyroidism is diagnosed by measuring the amount of calcium and parathyroid hormone (PTH) produced by parathyroid glands in the blood. If both are high, the diagnosis of hyperparathyroidism is made. But in 20% of cases of parathyroid tumours causing hyperparathyroidism have high calcium but normal parathyroid hormone (PTH) level.

The prostate is a small walnut shaped gland in the pelvis of men. Growths in the prostate can be benign (not cancer) or malignant (cancer). BPH stands for benign prostatic hyperplasia. Hyperplasia means abnormal cell growth. The result is that the prostate becomes enlarged. BPH is not linked to cancer and does not increase your risk of getting prostate cancer—yet the symptoms for BPH and prostate cancer can be similar. BPH may not need immediate surgery while in prostate cancer it depends on the grade and stage of the cancer and whether it has already spread or not.

 

While obtaining a history of a patient with knee pain, the following key questions should be addressed:

• Has there been an acute injury?
• Is a joint effusion present?
• Is there evidence of osteoarthritis?
• Are there mechanical symptoms?
• Is there evidence of systemic disease?

Knee replacement surgery is one option to treat knee pain and concomitant disability. But it may not be the first line of treatment for your knee pain and disability. Your age may be an important determinant. The meniscus is a C-shaped cushion of cartilage in the knee joint. When people talk about torn cartilage in the knee, it usually refers to a torn meniscus. A meniscal transplant surgery is another option in suitable cases. If an artificial meniscus is available then for younger patients (below 50 years of age) it may be the preferred option.

Our specialists at VirtualSathi would look at your full profile and take into account all relevant parameters to advise you the best and final solution that best fits most if not all your needs, concerns and expectations.

References:

• Parathyroid Disorders https://www.aafp.org/afp/2013/0815/p249.html
• What is Prostate Cancer? https://www.urologyhealth.org/urology-a-z/p/prostate-cancer
• History Taking and the Musculoskeletal Examination https://arthritis.arizona.edu/history-taking-and-musculoskeletal-examination
• Knee Pain and Problems https://www.hopkinsmedicine.org/health/conditions-and-diseases/knee-pain-and-problems
• World’s First ‘Artificial Meniscus’ Available in Israel https://www.odtmag.com/contents/view_breaking-news/2019-11-19/worlds-first-artificial-meniscus-available-in-israel/

Meniscal Transplant Surgery https://orthoinfo.aaos.org/en/treatment/meniscal-transplant-surgery/