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Plan of operating a National telemedicine network
Dr. S B Gogia 1. Introduction: The need for a working system of telemedicine is definitely there. As costs savings are enormous - this has been proved not only in Developed countries but also in developing Countries , . This is the one system capable of providing the high quality health care to the far reaches of the country. With the help of telemedicine, we are planning a system which shall provide quality and cheap health care to the needy populace utilizing existing health care providers in the private sector. 2. Background: In India, there is very little medical insurance, at least not in the Rural areas and Small towns, areas which are expected to benefit most from Tele Medicine. Sadly the Public Health providers have been unable to cope with the need due to various reasons. So, 75% of Health care services in India are provided by private practitioners. They are of various degrees of excellence, only some of them trained. They do charge for their services which may not be high quality but so far has been deemed as adequate due to the lack of better alternatives. As soon as there are any problems, the patient is asked to go to a higher centre which can be anywhere between 5 to 1500 kms away. A patient who is paying from his own pocket has to keep money aside for the following:- 1. Transport to the higher centre Patient + Relatives If there is a reasonable chance that these costs can be saved, the patient would be willing to pay a small fee. Overall, statistics of referrals to major centres do show that between 50 - 70% of patients being referred did not really need to travel all the way as no such procedure is performed which cannot be done in a smaller less costly setup close to the patients' residence. Thus, telemedicine can bring out real cost savings and can be made into an economically viable preposition just by saving unnecessary transportation of sick patients. Even if a procedure is performed, which means that the transportation was required, some cost savings will be evident even for that situation as 1. The patient can be fully worked up before a reference. 2. Online consultations can ensure that the specialist is fully aware of the patients' problem - thus no time is wasted in repeat investigations and the procedure is directly performed - and stay as well as hospitalization costs will come down. 3. The patient is aware of who is the right specialist he needs to go to so he is no longer at the mercy of the Auto-rickshaw driver. Not only can the uninformed patient be fleeced in the transportation charges, but also more importantly, he may go to the wrong specialist and pay for unnecessary procedures. 4. Once the referring doctor is fully appraised of and is part and parcel of the treatment plan, he can easily provide follow up at the patients' doorstep - he can consult the specialist with relevant details as and when required. Thus a chargeable Telemedicine system - which provides the patient online consultations, works up patients in its own small centre and sends patients for procedures only to the higher centre as and when unavoidable, and helps conduct the follow up too can be a economically viable centre which will provide yeoman service to the community as well as help in providing all levels of quality healthcare to the rural population. 3.1 Level ONE OF THE SOLUTION IT caters to the needs of the General Practitioners having independent clinics or small nursing homes and helps in the maintenance of basic records of patients as well as creates the Telemedicine consultation document for referral to the Telemedicine centre. 3.1.1 Inputs required for level one 1. Identification of Family Practitioners / Doctors who will send the patients and creation of their profiles and special needs. The best way to identify these is to ask the Level Three providers as to who send them patients regularly. 2. Supply of hardware and Software 3. Management of Hardware / Peripherals like Scanners etc and Support / Maintenance of Software A team of data entry operators who shall have basic computer skills of maintenance of hardware and operations of our software shall be trained and made available for the Family Physicians to work with them. Initially they will be under our payroll but after the initial break in period of 2-3 months, The Physician will be encouraged to manage without him or retain him on his own payroll. 3.1.2 RECOMMENDED HARDWARE
3.2 Level TWO OF THE SOLUTION
The Telemedicine centre shall receive the document from the referring physician and transmit to the consultant. Further requirements by the consultant like CT scan, MRI, etc shall be organized at this level. The report from the consultant shall be remitted back by this centre to the referring physician. This is not initially required but will be the very base to allow widespread usage. 3.2.1 Inputs for level two Server Software that shall receive client inputs Hardware /Software maintenance Trained personnel for running the centre as well as creating the liason between levels one and three. Staff needed here will include (at least one or more) Doctors 3.2.2 RECOMMENDED HARDWARE
3.3 Level THREE
The Consultants, whose opinion are being sought. Institutions like AIIMS have to be persuaded to be in this level. 3.3.1 Inputs for level Three 1. Profiles of Target Consultants who will provide Telemedicine services. They can be the specialist hospitals initially and later the Individual specialists. 2. Consultant level Software and hardware is optional. They can easily be provided a hard copy and their views noted through a secretarial service provided by the Telemedicine project vendor. 3. Premier Institutions may be provided equipment by the level two provider at cost, that may be realized through the payment made by clients for level two and the Institution shall be bound to provide the services. 3.3.2 RECOMMENDED HARDWARE
4. How to Begin -The Time period Centres like Escorts, AIIMS and Narayan Hrudayalaya are already providing linkages as they have the High End equipment in place So - Induce existing hospitals in Medium or Large towns to take up telemedicine for linking up with these super specialist centres in metropolitan towns. These shall be Level One Centres with Video Conferencing and other high end equipment. Progress on this has already started. Some places already have the equipment and are already linked. More centres are coming up- one in Bhopal and one in a peripheral area of Delhi should have the equipment in place with in two - six months. Induce the existing feeding doctors of such Hospitals to consult them online using the same equipment. These will be Level One Centres with low end equipment connecting to the hospitals and specialists in the large towns. Four to Twelve Months Once a few patients do manage to get the benefits of an online opinion, the needs will expectedly be felt by more peripheral doctors as well as Hospitals which will help spread the word. One Year onwards Hospitals which provide linkages two ways - both to smaller centres as well as to general practitioners will work at all levels. Simultaneously, induce the progressive centres in the peripheral areas as well as diagnostic centres to upgrade to higher end equipment which can link them up directly to metros. They can be converted into regional Level Two Centres One Year onwards Use this base of possible referrals; go to more specialists who would like a link to their favored Family Practitioners. One Year onwards Induce more specialist centres to join the Telemedicine network. Throughout And thus the seeds of a National telemedicine network shall be born. Two to Five years 5. A Few Basic Steps on Equipment and quality To truly provide a widely based National Network, not only should all the equipment be able to talk to each other, (i.e. Follow the same standards), but also have the same database structure which will allow seamless interconnectivity as well as transfer of data. 5.1 The nationwide database structure (our own Standards) Data will be stored at the level of all the doctors or users of telemedicine. They will have to use an RDBMS backend which will allow SQL type queries. The centres utilizing the services can be induced to computerize their patient records simultaneously. The proposal makes sense as the same record can then be easily transferred electronically, otherwise, record creation for Referral purposes is painful enough to make the staff in the peripheral centre unwilling to transfer. A unique identification code in India for our populace is still being worked out. We are not using Social Security Numbers (there are none). Smart cards or identification methodology is being worked on by the IT Ministry but the basic patient card structure can set aside points to utilize this. The proposed recording method is outlined in the above article but the philosophy can be underlined as follows (Also see the accompanying box) All centres keep the records in the same format. All patient data is linked to this master card, utilizing the CR_no as the Primary/ Foreign Key. Each centre which is part of the network is allotted a unique identification code. Records are transferred only if required. The records are manually exported in a simple format The unique identification of the transferred record is maintained in the file name itself. The higher centre maintains a copy of the records which are imported directly into the database as and when a referral call occurs. This would result in the following benefits: o Maintain privacy and security of data of individual centres.
Telemedicine equipment - essentially a PC along with telemedicine compatible Diagnostic Machines will be required at all locations where it needs to be installed. These are already being made in India and are of the best quality in the world. Communication link has to be tailored according to availability. The current systems allow flexibility and can adjust to any or all. The recent progress and availability of Mobile phones has improved the situation to a large extent. Since this is a private initiative, funding should be by the individuals who are participating in the project. They are expected to charge for their services and therefore should pay the initial cost. Bank loans can easily be arranged- many banks are anyway flush with funds and are calling up doctors themselves for providing a loan. However, for the initial period (first six months or so} some form of deferred payment or grant to the initial users of equipment will definitely help. These possible beneficiaries are easily identifiable as follows:- Hospitals in Small Towns who have shown an interest especially if they are already linked up with specialist centres which already have Telemedicine Equipment (Level Two) Referring Doctors of choice of Small hospitals who buy the equipment. (It makes no sense that both the small hospital and its referrers are funded.) The payment needs be deferred for only two to four months till they start earning 6.1 Recommended Charging system The provider of services to the patient - be it the Level One physician or Level two has to charge the patient. A proper method for the scope of work to be done as well as distribution of income to the different levels is shown in the accompanying chart. 6.2 Legal Responsibilities The norm at most places where telemedicine is working is that the final responsibility for executing a consultation lies with the physician who is physically examining the patient. The same holds true here too. A consultant can only utilize the information available to him to provide the advice. If the referring physician can prove that all information has been provided, the consultant can be charged by him. The patient however cannot file a suit directly against the consultant. TABLE 2: Benefits of Telemedicine For Primary care Utilizers Of Services ii) Håkansson S, Gavelin C. What do we really know about the cost-effectiveness of telemedicine? J Telemed Telecare 2000; 6(suppl 1): 133-136. iii) Richard Woolton Telemedicine BMJ 2001;323:557-560 ( 8 September ) iv) S. B. Gogia Towards A Unified System Of EMR / Telemedicine For Our Country Or Our Own HL X.. www.iamiindia.org/journal
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