The topic that is coming up for your consideration may require a rather unusual introduction in the form of enacting a fictitious, but not improbable, scenario:
A man in a remote village, aged 53 years, experiences a feeling of constriction in his chest associated with breathing difficulty and sweating.
The village has rudimentary medical facilities in the form of a dilapidated dispensary that is run by a nursing technician who is not able to read the ECG correctly but is capable of recording an ECG, monitoring vital parameters of a patient and administering parenteral medications. Fortunately, the medicine inventory is adequately maintained, and the village has excellent communication facilities with the nearest district hospital that has a satellite phone and a satellite data link.
The smart medical assistant records all the necessary details and transmits the data to an internal medicine specialist far off in the district hospital. This specialist renders advice to the medical assistant. The assistant, in turn, follows the instructions and saves the patient.
In short, this hypothetical situation depicts the ideal setting and implementation of a new avenue of health care that involves not only clinical acumen but also a state-of–the-art technology working in conjunction to bring about clinical succor to the patients.
What is telemedicine?
If the preceding example didn’t clarify the scope and ambit of telemedicine, then some definitions might help. Classically, –
The above definition may not be acceptable in certain circles. As an example, the World Health Organization (WHO) includes preventive health care in the purview of telemedicine.
Telemedicine in digital health, per se, is not a medical specialty unto itself. Rather, it constitutes infrastructure, personnel and requisite equipment used by a health care institution or establishment to provide specialized medical care in remote areas.
The concept of telemedicine is not a novelty for the modern era. For centuries, villages in the interiors of Africa, for example, have been known to convey messages by sounding drums. The beating of these drums in specific patterns conveyed different messages to neighboring villages. The system is still in vogue to summon help of any kind, including medical emergencies. These drums are also sounded to warn other villages of an impending epidemic.
In the early 20th century, the rugged Australian outback saw the use of two-way radios to convey emergent information and requisitions for help to remote places.
The modern-day telemedicine was born as an offshoot of a NASA application in which the vital parameters of astronauts in space were remotely monitored by the ground-controlling stations, and any medical intervention, if required, was accordingly advised. With the advent of newer technologies, the applications were expanded to health care rendered in remote places.
The words Telehealth and E-health are also closely associated with telemedicine. Telehealth is a further improvement upon telemedicine in that it goes beyond the curative aspects of telemedicine and includes preventive and promotive angles to the mix. All of these require a virtual consultation.
Types of telemedicine
Store and Forward:
This is perhaps the oldest and most simplistic way of practicing telemedicine. In this method, the medical data that includes the detailed history, medical images and biomedical parameters, are stored and transmitted electronically to a specialist for his or her perusal at a convenient time. The interaction between the patient and the physician is not synchronous.
This type of telemedicine is usually undertaken in non-emergent conditions and is more conducive to specialties like Radiology, Pathology and Internal Medicine.
Since there is no direct patient-to-physician interaction, the clinical examination is, in effect, thrown out of the proverbial window. The physician relies on detailed history and biomedical parameters to plan further management of the patient.
As the name suggests, remote telemonitoring entails monitoring of various medical parameters of a patient by a physician at different times of the day.
The data may be collated and then sent as a consolidated file or may be monitored in real time.
This modality is usually employed to manage chronic diseases like ischemic heart disease, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, asthma, etc.
Interactive telemedicine involves a direct one-on-one interaction between the patient and the concerned specialist. There may be the presence of a general practitioner at the patient’s end who may, on specific instructions of the specialist, help in demonstrating the specific signs of the disease and also carry out a detailed clinical examination as required.
This form of telemedicine is very effective in patients requiring psychiatric consultations but is not in the vicinity of a specialty clinic.
The main advantage of interactive telemedicine is the availability of specialist services to remote corners, thereby bridging the time and distance gap effectively.
Various studies carried out show equal efficacy of treatment protocols when compared with face-to-face consultations with a physician.
It is extremely cost effective and provides an excellent way for health planners to overcome the inherent problems of an eschewed physician-patient ratio.
Emergency telemedicine, as the name suggests, is used in cases in which a patient is in a remote location with limited medical facilities and a paucity of trained specialists. A case is discussed by a medic or a paramedic, who is in close vicinity of the patient, with a specialist located at a remote location, and emergent intervention is carried out on the advice so obtained.
Many countries, including Brazil, Chile and France, have procedures in place to carry out such measures. There are dedicated specialists who are on call to attend to such emergencies.
Medical emergencies aboard airborne aircrafts have been tackled by the aircrew by following the instructions of a specialist located somewhere on the ground. The patient is managed temporarily until the aircraft is landed.
Equipment and technology requirements
It is amply clear that electronic communication equipment is required at both ends–one at the remote location where the patient is situated and the other at the node where expert medical advice is readily available.
To capture the data, one needs a high-resolution video camera with a microphone that can help in capturing video clips of the patient, a scanner to capture ECG recordings, etc.
To initiate a one-on-one link or transmit the data for an asynchronous connection with the physician, a PC or laptop with high-capacity data link is required at both ends.
The instructions provided by the specialist can be conveyed in real time through a microphone at the physician’s end and received at the remote locality through speakers.
Of late, even smartphones can be used to carry out these tasks, as the present day crop of phones house some powerful processors and are capable of handling heavy volume data containing high-resolution images, audios and videos. Moreover, the presence of microphones and multiple cameras in the smartphones helps to miniaturize the entire concept of telemedicine consultation and extend its range to any place that a smartphone can access.
Social and chatting applications, such as WhatsApp and Skype, can also be used in emergencies to transmit medical data for urgent consultations.
Other applications and trends in telehealth
Telemedicine can be used in most of the medical and paramedical subspecialties, though a few of these branches may not provide a similar level of clinical benefits to remotely located patients as some others can.
One of the best applications of telemedicine has been carried out by transmitting the ECG recordings from a remote location that may include moving an emergency medical vehicle to a physician who can advise intervention as required. The transmission of the data can be done wirelessly, as has been demonstrated in a pilot project in India in 1975. The data can also be transmitted over a standard copper wire telephone network with the presence of a modem (modulator-demodulator) at both ends.
The same wireless system has also been used to wirelessly monitor a pacemaker that has been implanted in a patient. Any discrepancy seen in the cardiac rhythms can be monitored and corrected remotely.
Teleradiology is perhaps the most popular application of telemedicine and involves up to 50% of telemedicine usage. This usually does not involve face-to-face or a videoconferencing type of telemedicine application.
Medical imaging devices, such as CT scan machines, PET scans and MRIs, are used to generate an imaging study of the patient, and the high-resolution images are then sent from a remote place to a clinic or institution where a radiologist is available. He or she accordingly opines upon the data that is provided. Teleradiology requires a high-capacity data link between the two points and a requirement of high resolution imaging equipment at the end where the radiologist is located.
Another often-used application of telemedicine, telepsychiatry, is usually carried out with videoconferencing as a one-on-one session with the patient and the treating physician. Telepsychiatry has been used for first-time consultations, monitoring of therapy and subsequent follow-ups.
Telepsychiatry has been extensively used by military psychiatrists to give consultation to troops who are located in intensive combat zones where post-traumatic stress disorder is very common.
Telepsychiatry has been used in the rehabilitation process required by those suffering from substance abuse disorders.
Here again, a very simplistic module of telemedicine is applicable in which consultation on the microscopic appearance of blocks and slides can be obtained from a specific specialist located far away. This, again, does not require any high-end equipment, and a standard data connection can suffice.
Videoconferencing and image relay can help remotely located patients suffering from dermatological disorders. Though extensively used in the peripheral centers, it seems to take much longer time than a standard face-to-face consultation in clinical settings.
As of now, teledentistry is not as evolved as other medical specialties that are linked with telemedicine. It is largely used as a preventative and educational tool.
A hearing-impaired patient is subjected to clinical and audiological evaluation of his hearing acuity. Pure-tone audiograms can be generated at a remote location, even with certain smartphone applications and a set of standard headphones.
Any hearing deficit, if required, can be managed by prescribing augmentation of residual hearing with hearing aids that can be programmed and couriered to the patient. These hearing aids can subsequently be reprogrammed remotely as per the patient’s requirements and response.
The boon of telemedicine has been extended to the area of rehabilitation. Telerehab has two major components. The first and foremost is to assess the clinical disability of a patient, and the logical follow-up is the intervention required to manage these disabilities.
Telerehab, as it is often called, is specifically useful in speech-language pathology, audiology and occupational and physical therapy. Because of its nature, it requires a lot of audiovisual aids to gauge a patient’s disability and, accordingly, provide the suggested intervention modalities.
Regulations and Law
To shield the medics and paramedics involved in telemedicine, it is important that standardized laws and legislations be enacted that are applicable and acceptable not only in a particular country but also internationally. This needs to be put in place early so that newer and more complex technologies like robotic surgery can breed and subsequently evolve. Regressive laws and mindsets would be harmful in the long run for the science of telemedicine.
Dissolves the concept of time and distance to provide medical care at remote locations
Is cost effective
Takes care of an adverse doctor-patient ratio in a population
A very handy educational tool
Despite its astounding potential and real-life applications, there remain a few downsides that need to be addressed in the future. Some of the shortcomings are as follows:
-The system is extremely equipment-intensive. One cannot put into place an adequately functional node without having a transmitting, recording and analyzing mechanism at either end of the proposed communication channel.
-The individuals at either end should be well versed and trained to use the sophisticated equipment. They should be knowledgeable enough to amalgamate technology with available medical resources.
-To date, most of the work on telemedicine has been carried out by individual institutions or NGO Some high–profile, privately owned health care chains have taken it upon themselves to provide health care to remote places through telemedicine. To provide a worldwide reach of health care to the most remote corners of this planet, it is imperative that the governments of various countries take it upon themselves to assure health care to their population, even in far-flung regions, by investing extensively in establishing a telemedicine infrastructure on a national basis.
-Comprehensive legislation needs to be in place so that neither the institution nor the treating specialist may be exposed to litigation. There still seem to be many lacunae in the policies governing laws of telemedicine in many territories.
-Certain specialties are not too conducive to telemedicine. One of these is dermatology, which, if practiced as telemedicine, may be more time-consuming than the patient-to-physician direct communication.
-Surgical specialties still seem to have limited scope, but, with the advent of newer technologies like robotic surgery, these limitations may also be short-lived.
-A major drawback of telemedicine is the security of the medical data that is generated. There have been instances of hackers gaining access to confidential patient data, thus exposing the concerned physicians and institutions to numerous litigations.
Some statistics–telemedicine a bloom, then a boom, and, in the future, a definite boon!
In a study carried out by Park Associates, it’s been estimated that 2014 saw 5.7 million video consultations between patients and their physicians in the United States—an impressive figure indeed! What is astounding is that this figure is likely to grow by almost three times to a staggering 16 million in 2015.
The same study group revealed that almost 42 percent of households in the U.S. with broadband facilities had gone in for at least one telehealth service provided by different institutions.
Robotic Surgery: Though having limited applications as an extended tool of telemedicine as of now, robotic surgery is the future of telemedicine whereby a particular specialist located thousands of miles away can operate on a patient and render his/her expertise without being in the vicinity of the patient.
Smart wearables: Thousands of TV and Internet advertisements propagate the latest trends in health and fitness-smart wearables. Pint-sized wristwatches, headbands, wristbands and chest wraps monitor a multitude of parameters, the most common being heart rate, sleep patterns and daily activity monitors. Primarily used as a tool for monitoring and analyzing fitness levels, the application of these devices can be easily extended.
In the era of miniaturization, in which computing power has been placed in the palms of an individual, it would not require rocket science to devise applications and protocols for distant monitoring of individuals. As an example, one of these applications is called “Angel,” which is a GPS tracking device that has been specifically designed for autistic children. The device has a built-in GPS tracker patched onto an application in a smartphone. One can retrieve the location of the wearer any time of the day. It automatically generates text alerts if the child deviates from his normal routinely visited locations.