Telemedicine in India

TELEMEDICINE IN INDIA

Telemedicine in India

Telemedicine is a method, by which patients can be examined, investigated, monitored and treated, with the patients and doctor located in different places. Time magazine coined the phrase as ‘healing by wire’.

The availability of telemedicine is dependent to a large degree on telecommunications, and on high bandwidth; the field is concerned with advanced telecom equipment and standards, methods of increasing effective bandwidth and network performance, costs of installation and operation, security, confidentiality and reliability, and with government legislation aimed at furthering progress in these areas.

Thanks to the explosion in communications technology truly making the world a global village, it has now become possible to diagnose a medical problem, supervise a surgical procedure or give a doctor or a paramedical health worker in a rural area valuable health information from hundreds, if not thousands, of miles away.

Andhra Pradesh government has embarked on a huge broad band project with private consortium. It plans to cover all the villages in Andhra Pradesh within three years. Each village is proposed to be covered with 100 MB and each mandal with 1 GB connection. How ever though they will use fibre to connect most of the mandal (small block) they need WIFI and other technologies to connect to the final village.

The major technologies to be employed are Digital Video Broadcasting (DVB) using CODECS of Tadiran, Israel, TDMA Satcom of VIASAT, USA with Voice Over IP products of ARELNET, Israel.  BEL will integrate above technologies into a single platform and provide end to end solution for APNET.

Apollo telemedicine	Apollo group	A 50 bed hospital in Aragonda village (population of 15,000) of Chittor district in Andhra Pradesh  is connected to the Apollo group main hospitals in Chennai and Hyderabad through a satellite link.  The center is equipped with facilities such as an operating theatre, a computed –tomography scanner and software. Doctors the telemedicine center can scan, convert and send data images via satellite link to the tele-consult stations at Hyderabad and Chennai.
Narayana Hrudayalaya		Narayana Hrudayalaya, located in Bangalore is developing as a hub for telecardiology networks with a joint venture between the governments of seven hill states, Government of West Bengal, Karnataka Health Systems and ISRO to create a chain of coronary care units in remote areas and offer modern cardiac care infrastructure. The communication networks between these areas will be arranged through VSAT communication provided by ISRO, free of cost. The Heart Hospital is created as a social welfare venture where 60 per cent of the beds are reserved for working class families who will be offered treatment at subsidised rates. The charitable activities of the institutions is supported by Kiddies Heart Foundation, Sarojini Damodaran Charitable Trust, Mathrubhumi Medical Trust, Bagaria Trust, Prime Minister’s Relief Fund, Chief Minister’s Relief Fund, Health Minister’s Relief Fund, Mithun Chakraborty’s Amra, Society for Indian Children’s Welfare, Rotary and Lions Clubs and various other philanthropic organisations.
Pune Primary health telemedicine project	The Pune district administration	The Pune district administration has teamed up with doctoranywhere.com and Tata Council for Community Initiatives (TCCI) to launch a telemedicine service from a government primary healthcare center (PHC).  The service, launched at three healthcare centers, is targeted at the rural masses. There are 88 PHC's in Pune district, each in-charge of five to six sub-centers. Each PHC has two doctors and basic medical facilities, including operation theatres, laboratory and a pharmacy. It also has 15 personnel who travel to the sub-centers to implement government medical programs.   The telemedicine project, later aims to connect all PHC's in the district. In the first phase, three in Wagholi, Chakan and Paud regions would be linked with the district administration of Pune and the specialists.  There are at least five to six doctors always present at the headquarters who can respond even if there are no specialists.   Ten specialists (two each from each category) have been chosen from dermatology, nephrology, neurology, cardiology and gastroentrology. Doctors at the PHC refer complicated cases to the specialists in major cities who in turn will give their advice within 24 hours. The TCCI has donated three Pentium computers for the project. The district administration will provide computers to other PHC's. The service has started at the PHC's at Hole in Baramati tehsil, Otur in Junnar tehsil and Nirgudsar in Ambegaon tehsil and in another 40 PHC's within a year

Expected Benefits

·         Timely access to diagnostic, specialty healthcare advice at the grass root level through the low cost telemedicine network centering around the district hospital as the service provider

·         Augmented rural healthcare delivery system by integration of low cost, sustainable, scalable fixed, mobile and hand-held telemedicine technology platform into existing rural healthcare services infrastructure

Mobile Telemedicine Unit covering few villages connected to nearest PHC / CHC or directly to District Hospital

·         Automobile Vehicle

o    Chasis Size: 5.779 X 2.188 X 1.900 mts

o    Customized fabrication to accommodate IT and medical equipments

o    Integrated DG set

o    Space for tele-consultation, patient examination

o    Space for carrying out investigation procedures like Ultra-sonography and X-ray

• Telemedicine Platform

o    Selective medical and medico-IT equipments, preferably IT compatible, with interface to Telemedicine and/or other IT software / hardware

o    Computer hardware / software platform (PC, server, switch, etc.) and IT electronics equipments

·         Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless)



Simulation and clinical skills development

It is acknowledged worldwide that simulation training is an useful and  value-added precursor to actual clinical work for healthcare workers.

Simulation is becoming a norm and an essential part of pre-clinical training in several countries and reputed institutes worldwide. Some examples:

1. Skills Development ... - Queensland Health - Queensland Government

(http://www.sdc.qld.edu.au/)

2. EISE ( Ethicon Institute of Surgical Excellence) , India

 http://www.jnjindia.com/EISE_Index.asp

3. Medical Simulation Centre, Rhode Island Hospital

http://www.rhodeislandhospital.org/rih/services/simctr/

The Apollo Group of Hospitals has set up a clinical simulation centre at Hyderabad. In addition, Defence R & R Hospital, Delhi and AFMC, Pune have facilities for clinical simulation.

Presenting a conceptual note on Clinical Simulation Centres:

                     1.CPR (Cardiopulmonary Resuscitation)  Lab :

This would be utilized for BLS, ACLS, NALS and PALS classes. CPR mannequins are used, which provide training in CPR, AED use, and the Heimlich maneuver. Airway, breathing and circulation systems are simulated and the results of interventions can be demonstrated.

A CPR mannequin for practicing cardiopulmonary resuscitation of a human has a simulated human head and neck portion with an air passage extending from a mouth opening to a neck opening in an end of the neck remote from the head. An inflatable simulated human chest portion is secured to the neck and has an upper flexible wall member, a lower wall member and a flexible bag there between and a further air passage connects the air passage in the neck to the flexible bag. The upper flexible wall member simulates a chest which rises and falls with inflation and deflation of the flexible bag.

The types of mannequins required would be-

a)    Adult mannequin for BLS

b)    Adult mannequin for ACLS

c)    Pediatric mannequin for PALS

d)    Neonatal mannequin for NALS

     Other than these, the following would be required-

e) 3 demonstration rooms with Seating Capacity for 20 people each.

f) Audiovisual equipment

                           2. Airway Management Lab

     This would be utilized for teaching of airway management to physicians, nurses and paramedics. It would be provided with a  

      variety of simulators including pediatric and neonatal models.

A mannequin such as the Human Patient Simulator (HIPS) system is used, which contains a self-regulating pulmonary system which regulates the body’s O2 requirements and rate of CO2 production and automatically adjusts the respiratory rate and tidal volume. Breath sounds are auscultated by standard stethoscopes in several locations to detect abnormalities. A number of techniques can be taught using the anatomically correct airway. Bronchoscopy can be performed in the upper airway and trachea. Nasal or oral intubation can be performed. Ventilation can be compromised by tongue or upper airway swelling, bronchospasm, or laryngospasm. If an esophageal intubation is performed, the stomach swells up when ventilated.

During a tension pneumothorax, the adult manikin allows either needle decompression or chest tube placement. The treatments are performed through the computer interface for the pediatric manikin.

                                          i.    Access Management Lab

Access Lab would have realistic models for both peripheral and central venous devices, placement of Intercostal catheters, and Spinal Punctures, Regional Anesthesia etc. The mannequin would simulate vascular access and fluid management. Infusions of whole blood, packed cells, crystalloids and colloids independently (artificial solutions), can be carried out. The patient can lose either whole blood or plasma, to simulate the different effects of blood loss through active bleeding versus volume loss through leakage into extracellular spaces.

                                        ii.    Emergency and Trauma Management Skills Lab

     Trauma management skills are taught using mannequins, audiovisual aids and life support stations.

                                       iii.    General Surgical Skills Lab

It provides simulated hands on surgical skills to a minimum of 15 learners at the same time. Each student is able to see the skills being taught by the teacher, on the monitor and then perform the same at his/her station. All the skills are supervised by a team of dedicated trainers.

                                       iv.    Laparoscopic Surgery Skills Lab

This would contain a Laparoscopic Trainer station that includes an introductory board, several anatomic models, and a camera for training in laparoscopic surgery skills. Trainees begin on the introductory board. Stations demonstrate basic skills which will be incorporated into many real surgical procedures. Once the trainees are comfortable in the laparoscopic environment, the introductory board is removed and various surgical anatomic models are placed in the trainer, each of which will be used to teach operating techniques or full length procedures.

                                        v.    Endoscopic Skills Lab ( Lower GI / Upper GI endoscopy)

This would contain a endoscopic model, consisting of a endoscope, a box containing the computer components, and a screen to view images. Cases are grouped, to allow trainees to focus on basic principles (introduction module) or to learn biopsy or polypectomy procedures. Within all modules, the simulator gives instructional information beforehand, real time patient feedback during the simulation, and constructive feedback after the simulation has been completed.

The endoscope is shaped like a real colonoscope, including all the directional controls and adjunct buttons. The functionality has been removed from the scope, although the simulator senses what the user is doing and causes the image to change appropriately. During the case, the simulated patient responds in real time to the trainee's actions, both verbally and with vital sign changes. The modules contain a series of videos and text instructions.

                                       vi.    Bronchoscopic Skills Lab

The fiberoptic bronchoscopy simulator consists of an anatomic model of the face, with an opening in one nare for nasal insertion of the fiberoptic bronchoscope. It has an attached motion sensor system and a video system with screen for the images. As the user inserts and manipulates the bronchoscope, the simulator senses the movements and adjusts the screen images in real time. The respiratory tree and the full length of the bronchoscope are visible as it is currently positioned. 

Feedback is given during the procedure (such as an audible patient cough if topical anesthetic is insufficient) as well as after the procedure is complete.  Other output is intended to help the trainee develop a personal technique (such as the order the bronchial segments were visited).

Modules within the bronchoscopy simulation include basic maneuvers, lesion visualization, bronchial lavage, and tumor biopsy. There is also one pediatric difficult airway module.

      3.         Cath Lab, Imaging Lab, Neuroelectrophysiology Lab and other Labs as identified would be required.

In addition, Demonstration Rooms, Lecture halls and Audiovisual Aids would be required for teaching.

New hospital new thinking

 Sharing the story of how NHS Wolverhampton, UK, met patients's expectations:

http://www.ashridge.org.uk/website/IC.nsf/wFARATT/New%20Hospital%20New%20Thinking/$file/hospthink023.pdf

Who said doctors can’t be ethical and successful?

(This article was published in The Hindu on July 24, 2011)

-By Dr. K.R. Antony

http://www.thehindu.com/opinion/open-page/article2288190.ece#comments

When doctors enrolled themselves in the profession, they are bound to observe certain professional ethics and decorum. That is not for sainthood but for the upkeep of a certain code of professional conduct which was practised by our seniors. That gave us the social recognition and dignity we earned collectively.

Now there is value erosion, everybody admits. Breach of medical ethics is seen not as grave, restrained and punished timely, but is being overlooked and condoned easily as an “inevitable evil of the prevailing conditions.”

The strength of the majority is not used to correct the wrongdoing of a minority, but to justify its misdeeds and approval by the whole body as a “survival strategy.” Professional associations are also resorting to strikes to safeguard their business interest and protection from the “public” whom they are supposed to serve. The old fashioned and the not-so-smart ethically practising doctors are becoming a minority. Even a laughing stock! No wonder, the same society that treated us once as “god” is now treating us as “dogs” as lamented by Dr. Manorama Gadde (Open Page, The Hindu, July 17, 2011).

Who is at fault? Rather than taking it to the “media” accused of using “doctors as punching bags,” it is high time for introspection.
What happens, for example, if we refuse to pay 25 per cent of the fees to the local RMPs to get referral cases? My firm belief is that if a doctor is ethical, skilled and very good in his/her profession, people flock to that doctor. Client satisfaction is the best advertisement for a doctor or hospital. People may be unlettered, but their wisdom can differentiate the bad from the good doctor. It is only the mediocre and below average who need advertisement props.
I have seen very poor patients travel from far off tribal areas and districts and across State borders to Ganiari near Bilaspur city to receive the good services of a group of committed specialist doctors who passed out of the AIIMS, Delhi. These doctors do not even put up a decent nameboard.
I started paediatric practice in a 150-bed mission hospital in a rural area where not more than five or six patients came a day. Within a few months, the number grew up to almost 90, and it became unmanageable for me as a specialist to give quality time and attention to my patients. Finally, I was compelled to restrict my outpatient tokens.
Many local practitioners referred patients to me, instead of to the district headquarters hospital, because they knew I did not pass any remark on the missed diagnosis or the not-so-correct case management by the referring doctor. Moreover, would get a return referral slip, in a sealed cover, on what the diagnosis turned out to be upon investigation and the lines of management that I followed.
In India, no qualified doctor willing to practise ethically is going to starve. There is enough revenue generation from consultancy for everybody’s need, but may be not enough to everybody’s greed. The “greed” is often perceived and firmly believed as “need” when you actually embark upon certain ambitions of life for the sake of survival in cut-throat competition. One more building block, one more operation theatre, a CT scan machine and similar sorts, for which banks are ready to advance loans fast but also quick to retract when EMIs are delayed. The stress is passed on to the middle class patients who might not have actually needed it at all. Why join that rat race?

(The writer is a former Health & Nutrition Specialist for UNICEF and former Director, State Health Resource Centre, Chhattisgarh. His email id is krantony53@gmail.com)

Health Insurance – A Perspective

 

Dr L Rathika MBBS DFH

With escalating costs, healthcare has become a high priced commodity. In the changing economic scenario, health insurance is no longer a luxury, but indeed a necessity.  More and more households are opting for health insurance cover to tide over the unexpected hospitalization expenses. Nowadays, it is a common practice for employers to provide group health insurance coverage to their employees.

Indian Scenario

Indian Healthcare Industry contributes significantly to the country’s gross domestic product (GDP). In recent years, the concept of health insurance is receiving increasing prominence in India.  According to current research, health insurance market constitutes the second largest non-life insurance sector in India and has registered phenomenal growth in 2008-09 and 2009-10. Health insurance industry is one the fastest growing businesses and the premium mark is expected to cross a compound annual growth rate (CAGR) of 25% by 2013-14.

                                            

Health Insurance

Health insurance is a product that protects the insured person against the risk of incurring medical expenses and provides with specified sums to cover the treatment costs. In India, most health insurance policies cover only hospitalization expenditure.

Need for Health Insurance Cover

Most of the Indians receive healthcare through state owned primary care centers, as well as secondary and tertiary hospitals.  Nevertheless, only 6% of GDP is spent on healthcare. Poor state of government-owned healthcare facilities and the fewer number of hospitals per 1000 population as compared to global average have led to the exponential growth of private secondary and tertiary care hospitals, which constitutes nearly 80% of the country’s health infrastructure. This, among others has contributed to the escalation of healthcare costs. In addition, massive population growth is straining the already over stretched health infrastructure. Socio-economic changes such as ongoing migration of people from rural to urban areas in search of livelihood, sedentary life style, globalization and stress have contributed to the increased incidence of life style diseases such as diabetes and hypertension. Given this background, the need for health insurance is more prominent than ever, considering that merely 10% of Indian population has health insurance coverage.

Advantages and Disadvantages of Health Insurance Policy

Health insurance policy covers the risk of unexpected expenditure resulting from medical treatment. Most insurance providers offer cashless facility of claim settlement when the insured person gets admitted in the hospitals belonging to their preferred provider network, the details of which are made available while purchasing a health insurance policy. There are various health insurance products in the market, offering consumers with a wide range of choice to suit their specific requirement.  Some insurance providers offer discount on the premium amount for the succeeding year, if no claim has been made in the previous year on the policy.

More often than not, health insurance policies cover only hospitalization expenditure, and the cost of outpatient treatment is not generally covered. Moreover, most policies exclude the pre-existing diseases for varying periods of time when the policy is in force, and this makes it wiser to purchase the insurance cover at an early age. One of the exceptions is Star Health – Senior Citizen Red Carpet Policy, which offers coverage of all pre-existing diseases from the first year of policy. In addition, hospitals tend to charge health insurance policy holders at rates higher than the reasonable treatment cost, requiring the insured person to spend additional sums from his pocket.

Public and Community Health Insurance Schemes

The Government of India has increased the plan allocation for the healthcare expenditure from US$ 4.97 billion in 2010-11 to US$ 5.96 billion in 2011-12. Furthermore, the Ministry of Health & Family Welfare has proposed to increase the domestic healthcare funding by at least 2 per cent of the GDP in the 12th Plan period. Taking into cognizance the need for greater population health risk coverage, the central and state governments in India have launched innovative health insurance schemes to help the poor. Rashtriya Swasthya Bima Yojana (RSBY) was introduced by the Government of India for BPL (below poverty line) population in the unorganized sector in April 2007. Recently the government has approved extension of RSBY to cover registered domestic workers, which is likely to cover 47.50 lakh workers. Some of the popular insurance schemes run by the state governments include Aarogyashri in Andra Pradesh, Chief Minister’s Health Insurance Scheme in Tamil Nadu and Yashaswini Insurance scheme in Karnataka.

In addition, several community-based health insurance schemes are run successfully by NGOs across the country and a few of them are listed below.

·         Self Employed Women's Association, Ahmedabad, Gujarat (1992)

·         Goalpara, Shantiniketan, Rural West Bengal (1984)

·         Voluntary Health Services (VHS), Medical Aid Plan, Chennai, Tamil Nadu(1963)

·         Social Work and Research Centre (SWRC), Ajmer, Rajasthan ( 1972)

·         Sewagram Kasturba Hospital, Wardha, Maharashtra (1972)

Leading Health Insurance Providers in India

Though successful, existing health insurance schemes do not cover all sections of the society, thus leaving the field open to private players. Currently we have public sector general insurance companies and private insurance companies offering health insurance products. Of these Star Health Insurance is the only stand alone health insurance company. Leading health insurance providers in India include,

·         National Insurance company

·         New India Assurance Company Limited

·         United India Insurance Company Ltd

·         Star Health & Allied Insurance Company Limited

·         ICICI Lombard Insurance

·         TATA AIG Insurance

·         Royal Sundaram General Insurance

·         Bajaj Allianz Insurance

·         Oriental Insurance Company Ltd

·         Max Bupa Health Insurance

·         Apollo Munich Health Insurance

Popular Health Insurance Products

Some of the most innovative and popular health insurance products are,

·         STAR Health – Medi  Classic, Family Health Optima, Senior Citizen Red Carpet

·         National Insurance – Varishta Mediclaim

·         New India Assurance – Mediclaim policy

·         United India – Family Medicare

·         Oriental – Individual Mediclaim Policy

·         Max Bupa – Heart Beat Gold, Silver and Platinum

·         Bajaj Alliance – Health Guard

·         Apollo  Munich – Easy Health Individual -Standard Plan

Future of health insurance in India

Indian health insurance industry is on the verge of an exponential growth. Key factors driving this industry include escalating healthcare costs with resultant need to purchase private health cover to supplement public schemes;   sub-optimal quality of public health services;  booming population growth; increasing incidence of lifestyle related diseases; greater awareness and affordability among the educated middle class;  and deficiencies in pension schemes.

In conclusion, from the consumer stand point, it would be only prudent to purchase health insurance cover for the individual as well as the family — earlier the better!

AIA guidelines for hospital planning.

AIA guidelines for hospital planning:

http://www.scribd.com/doc/61018483

Staff who resist quality improvement efforts

-by Donald Tex Bryant


Perhaps you are just beginning a quality improvement program or project.  Perhaps you have several project improvement projects successfully completed at your healthcare site.
No matter what your level of experience, you have encountered staff who are roadblocks to your efforts.  What are you to do?  Ignoring them or doing nothing will imperil your quality efforts eventually.  Let me share some ideas on what to do based upon my own experience and on advice from experts.

Before I share some strategies I will share an example based upon my own experiences.  A primary care group with six physicians specializing in family practice and internal medicine has been focusing on process improvement and patient-centered care for six months.  They have retained a Lean healthcare consultant to help them with timely advice and occasional training.  The consultant keeps them focused on standard procedures, value adding processes and waste elimination and on continuous improvement, all of which are focused on the patient outcomes.  They decide to explore whether they should have their patients who come in for physicals have their blood work done a week before their scheduled appointment.  The office manager asks some of the physicians, nurses and office staff to come together for a few one-hour meetings before the practice opens for patients in the morning.  The goal of this team of volunteers is to assess the pros and cons of having the blood work done before the physical and if so, to develop a standard operating procedure (SOP) for having it done.  Some of the pros and cons are:

• Physicians will be able to discuss with the patients indicators such as triglyceride levels outside of normal ranges so lifestyle changes can be suggested
• Patients who are focusing on improving their health can discuss the results with their physician
• Some patients may find going to a lab before the visit an inconvenience, especially if the lab is in the same building or near the group practice site

Overall, the team decides that they will pilot this approach with two of the physicians.  A SOP is developed involving staff who schedule appointments, nurses aides and physicians.  Indicators of the outcomes in terms of patient health and  physician and staff  attitudes are developed and tracked.
The results of this pilot are positive and the office manager decides to implement the changes for the whole office.  She discusses the procedures with the rest of the staff and physicians and sets up a chart for her use and her staffs’ observation of the rate of compliance with the new procedure.  After a couple of months she finds that there is a lack of progress in improved compliance with the procedure.  Upon further investigation she finds that one of the schedulers and a nurse’s aide are consistently not following through with their procedures.  She talks to them about this and after a couple of months they are still not following their procedures.  What should she do?
According to a recent newsletter of Lifewings, a quality improvement group for healthcare, CEO Steve Harden stated that about 8% of staff of groups who are beginning quality improvement projects at their site will not participate or will actively block projects.  In the newsletter he advises that management have a plan in place to deal with these 8%.  Lifewings trainers get a verbal commitment from management that they will actively engage those who are blocking projects by having a conversation with them and trying to get them to commit to join in the improvement efforts.  Some will agree to but will still not change.  Some will not even agree.  Mr. Harden suggests that managers then ask these staff to find another place to work.  Further, he says to celebrate the achievements of those who have helped improve patient health outcomes through process improvement projects.
Jim Zawacki, co-author of It’s Not Magic, the Rebirth of a Small Manufacturing Company, suggests another approach.  In his book which describes the Lean quality improvement efforts at his company, GR Spring and Stamping, he describes how a team of managers and front line employees came to grips with those who would not join others as they started the cultural transformation necessary to ensure the success of a Lean Process Improvement program.  After the Lean program had been well established the team decided that management would have to ask those who were unwilling to change to leave the company.  Mr. Zawacki as CEO made sure that happened.
If you are just beginning quality improvement efforts at your site, you must come to grips with dealing those who will not join it.  Eventually, they will sabotage much of your efforts and will negatively influence those staff members who are involved.  Management should have a plan on how to consistently deal with the recalcitrant staff, including asking them to find other employment.  Do not let a rotten apple spoil the barrel.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.