Introduction to Telemedicine

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Introduction to Telemedicine

• Arun Raj Kunwar, M.D.
• Assistant Professor
• SUNY Upstate Medical University
• Syracuse, NY
• kunwara_at_upstate.edu

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Disclosures

• No financial affiliations or interest in any
  thing that will be discussed
• No commercial interest

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What is TM

• Use of telecommunications to provide medical
  information and services
• Health delivery/consultations via use of
  telecommunications
• -Telephone between two providers
• -Fax
• -Video conference
• -Robotic technology

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Types of Technology

• Store and forward
• -Digital images are stored and forwarded
• -Digital X-rays, digital photos, EKG faxes
• -Mainly used for non-emergent cases but done
  for some emergent cases too
• -Can be forwarded to anywhere in the world

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Store and Forward

• Teleradiology, the sending of x-rays, CT scans,
  or MRIs (store-and-forward images) is the most
  common application of telemedicine in use today
• -Most radiologists are staying home during on
  call
• Telepathology/ Teledermatology

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Two-way Interactive Television (IATV)

• Face-to-face consultation
• Provides a real time consultations via
  videoconference
• Usually patient with their primary provider gets
  direct consultations to expert in distant site
• Can directly involve patient

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IATV

• Widely used for urban-rural location where access
  to care is difficult
• -the patient does not have to travel to an
  urban area to see a specialist
• -availability of specialist services not
  available before

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IATV Videoconferencing equipment

• New ones are more simpler, cheaper and easy to
  use
• New programs now use desktop videoconferencing
  systems
• Attachment of peripherals to make it more
  interactive such as attachment of stethoscope and
  otoscope, blood sugar monitoring

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Often Combination

• Interactive
• Store and forward
• Audio-video still images
• Web to transfer data/other web application
• Web based/accessed health records
• Electronic prescriptions
• Wireless technology in emergency/ ambulances

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Application TM

• Health care delivery
• Health profession education
• Health administration
• Public health
• Business
• Libraries
• School education

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Benefit of TM

• Breaks down barrier to distance/access
• Improves quality of care
• -By direct patient consultations/
  consultations to primary care
• -By providing easy access to education
• May lead to decrease health care cost

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Application

• Urban to rural for specialty/unavailable care
• Mental health care to Jail population
• Hospice care
• Consults to school nurse
• Home telehealth and monitoring of chronic
  disease- Chronic heart disease

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Application

• Distant health teaching/ monitoring (video
  recording of exams)
• Telesurgery applications for battlefield via use
  of robot
• Teleradiology
• Telepathology
• Most of the medical specialty are using some form
  of telemedicine

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TM Experience

• SUNY Upstate Child Psychiatric Consultations To
  Binghamton General hospital
• -Child Psychiatry is a sever shortage specialty
• -BGH has been unable to recruit a child
  psychiatrist for some time

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TM Experience

• BMG runs a Child Psychiatry inpatient unit with a
  help of adult psychiatrists
• Child Psychiatrist located at SUNY Upstate at
  Syracuse consults via videoconferencing
• Typically includes, review of the case, talking
  with patients, families and treatment
  recommendations

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Barrier to Telemedicine

• Equipment and infrastructure
• -Most telephone do not provide enough bandwidth
• -Increasing web based application making it
  simpler
• -high bandwidth telecommunications access
  required for more sophisticated uses (Rural
  connectivity priority)

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Barrier to Telemedicine

• Licensing issues Many states will not allow
  out-of-state physicians to practice
• Reimbursement Many private insurers will not pay
  for it. In some states new laws that reimburses
  in same rate as face to face

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Barrier to Telemedicine

• Fear of malpractice suits physicians
• Acceptance of the technology and lack of hands-on
  interaction with patients
• (most patient satisfaction studies to date
  find patients on the whole satisfied with long
  distance care)
• Privacy issues
• Worry about depersonalizing health care

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Heath Care in Nepal

• Percentage of national budget in
  health                                     6.2
• Percentage of the current five-year plan
  allocation in health        6.0
• GDP about 5
• (Nepal Millennium Development Goals Progress
  Report 2005)

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Nepal

• 24.1 percent of the population earn less than an
  dollar per day
• 31 percent of the population is living below
  poverty line (Nepal Millennium Development Goals
  Progress Report 2005)

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Nepal Basic Health Indicators

• Hospital beds per 10,000 population 4.26 2001/02
• Number  Physicians per 10,000 2
• Nurses per 10,000 population 2 
• Urban population ()14. 2001
• (Nepal Millennium Development Goals Progress
  Report 2005)

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Population Distribution

• Due to the thinly scattered population profile in
  the hilly and mountainous regions, the
  accessibility to health facilities is still a
  problem Nepal

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Telemedicine Nepal

• Nepal has large rural population with limited
  access to medical care
• Most of the health care experts and physicians
  are located in urban areas-mainly Kathmandu

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Telemedicine in Nepal

• Regional hospitals are presently connected via
  internet for health information access
• Limited use of technology for education

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Ministry of Health

• Telemedicine Project in Developmental phase.
• ?Connect all health post center

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E-Network Research and Development

• Mahabir Pun
• have started the telemedicine program in three
  villages as a pilot project. Nangi, Ramche and
  Tikot, all of Myagdi District Myagdi District.

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(Note ngi Nangi, rmc Ramche, tkt Tikot are
the villages where telemedicine program has been
set up)
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TM Nepal

• Om Hospital Research Centre (P.) Ltd and Apollo
  hospital in New Delhi
• -Consultation
• Dr. Mohan Raj Pradhan HealthNet Nepal-Store and
  forward method feasibility study

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Center for Nyaya Health Achham

• Nyaya Health is a 501(c)(3) nonprofit
  organization working to improve the health of
  poor communities in Nepal through the provision
  of medical and public health services
• http//www.nyayahealth.org/about.html

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Center for Nyaya Health Achham

• Nyaya Health activities in Achham is a four-bed,
  five-room clinic focusing on primary care,
  maternal and child health, HIV, and tuberculosis
• Plans to develop Telemedicine to provide medical
  services at two sites in Achham

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Center for Nyaya Health Achham TM Plan

• Email-based communication with specialists
  regarding complex patients as issues arise
• Voice-based communication with specialists on
  complex patients, potentially even in emergency
  scenarios
• Communication from clinicians at the center
  clinic with Community Health Workers in the
  villages, for assistance with triage and
  treatment

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Center for Nyaya Health AchhamTM Plan

• Cytopathological assessment of Pap smears for
  cervical cancer, via transmission of images
  through digital microscopy
• Interpretation of complex ultrasound or X-ray
  images for direct patient care, training, and
  quality assurance
• Reading of complex microscopy slides for patient
  care, training, and quality assurance

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Center for Nyaya Health Achham Along with TM

• Microfinancing
• Selling of goods/promotion of business thought
  internet

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Shahid Gangala National Heart Center

• Dr. Jyoti Bhattarai Kunwar recently got funded by
  International Diabetes Foundation
• To compare the effectiveness of diabetes care via
  TM in rural health post Vs treatment as usual

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Nepal TM Goals

• Connecting all rural health posts to Internet
• Providing direct consultations for patient care
• Some specialty are easily adopted
• -Psychiatry
• -Dermatology
• -Diabetes management
• -Preventive health education

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Nepal TM Goals

• Partnering with leading international groups for
  expert and second opinion -Johns
  Hopkins Medicine International runs global
  "Medical Second Opinion" service
• Also for education

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Nepal Health Profession Education

• Most of the lectures are videotaped and can be
  accessed from distant site
• Live lecture feeds
• Case discussions
• Can lead to saving in cost of travel for health
  workers

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Nepal TM Barrier

• Lack of any law/regulation
• Rural and even urban connectivity/ bandwidth
  limitations
• Funding

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Other uses of TM to enhance health care in Nepal

• Electronic medical records
• Google health service

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TM Nepal Application

• Electronic prescription
• Known to reduce medication error/ saving
  significant cost/suffering

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Nepal TM Business Application

• Out sourcing
• Medical transcription
• Software development/Medical records
• Medical consultations- MDweblive.com
• Patient education

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QA