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Advances in Telemedicine

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• Telemedicine is synonymous with remote health care. The idea is that
health care providers can work with patients despite physical distance

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between them using digital communication. This process goes hand in
hand with health information technology (HIT), the electronic systems

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used to store, manipulate, and share medical data.

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• As recently as the beginning of 2014, many medical facilities still
relied on paper records, which are incredibly inefficient compared to

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their electronic counterparts. Now, the medical field is advancing
quickly when it comes to digital technology. Here are five of the most
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impressive advances in telemedicine and HIT in the last year.
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Wearable Medical Devices

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• A vast range of wearable medical devices are available for personal
and professional use. These devices can measure your heart rate,

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calories taken in and burned off, glucose levels, ECG, and posture, and

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they can even offer pain relief through electrotherapy.
• More and more of these devices are hitting the market all the time.

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According to Smithsonian Magazine, wearables and other digital
health devices took up 40 percent more space at 2015′s Consumer
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Electronics Show (CES) compared to 2014.
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Smartphones as Diagnostic Tools

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• Combined with wearable devices or attachable scanners, or
sometimes even alone, smartphones are becoming acceptable tools

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for self-diagnosis. Smartphones can diagnose mental conditions like

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Alzheimer’s with simple tests. Attaching an enhanced lens to a
smartphone’s camera can give it the power to diagnose skin and oral

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conditions. Scanners attached to smartphones can scan blood
samples for malaria, thyroid problems, and more.
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Health Informatics

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• According to a government mandate known as the HITECH Act of
2009, medical facilities have to update their HIT systems to comply

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with government regulations. While many hospitals still lag behind

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when it comes to meeting government standards for digital health
care, they are advancing every day to meet those requirements. As a

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result, the demand for jobs in health informatics has increased
dramatically in the past few years.
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Digital Therapy and Advice

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• One of the biggest advantages of telemedicine is that doctors can
more easily communicate with patients without an office visit.

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Therapists can receive information about their patients when a

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therapy app records a sample of their speech. Other apps like
Wellframe use artificial intelligence to give therapy and advice to the

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patient without a doctor’s interaction. ThriveOn is a similar app that
provides mental health care.
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New Apps Save Patients Money and Time

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• Apps that offer convenience to the patient ultimately save doctors
from jumping through hoops as well. These apps can help patients

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schedule doctor’s appointments, save money on prescriptions, and

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manage their health insurance. With these tasks out of the way,
doctors can focus on providing quality care during the time they

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interact with their patients.
• There is no telling what advancements will be made in health care in
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the next few years. As medicine advances into the digital age, HIT
systems and telemedicine promise to save doctors and patients a lot
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of work, as well as potentially saving lives.
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Drivers of Telemedicine and

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Telecare

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Drivers of Telemedicine and Telecare

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• Technological Drivers

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• Non Technological Drivers

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Technological Drivers

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• Computing and Information Technology

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• Network and Telecommunication Infrastructure

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• Technology led society

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Non Technological Drivers

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• Extension of access to healthcare service

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• Healthcare provision for travellers

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• Military applications
• Home telecare

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• Cost reduction
• Market development.re
• Health policy and strategy
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Types of Telemedicine

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• Teleconsultation

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• Teleeducation

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• Telemonitoring
• Telesurgery

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ETHICAL AND LEGAL ISSUES

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• Cyberspace is a fast-changing, globally-networked, multicultural, and
multilingual information environment with vast possibilities.

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• It calls into question, national and international borders, cultural and
ethical standards, regulations, and laws, which it bypasses and

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challenges. In the health sector, self-care, drugs sold over the

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Internet, and providing access to technical knowledge and alternative
forms of healthcare to the general public have destabilised drug

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regulatory mechanisms and the traditional physician-patient
relationship
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• Telehealth technology has existed for two decades, making healthcare

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available to many patients in remote and otherwise under-served
areas.

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• Many patients have benefitted by telehealth systems who would not

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otherwise have had adequate access to healthcare. Telemedicine has
also enabled distance education and the rapid, efficient sharing of

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information, not only with patients but also between providers who
are separated either geographically or within institutions.

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• Utilising this form of technology has been proved to be cost -ffective
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and has resulted in beneficial health outcomes for chronically ill
patients and for other vulnerable populations who find it difficult to
travel long distances to receive the needed care.
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• Patients have expressed satisfaction with telecommunication because of
the focussed and uninterrupted attention they get from their healthcare
providers. Providers have also been satisfied when using telehealth. From a

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technological and evidence-based standpoint, it would appear that the
virtual visit, like the face-to-face visit, is likely to evolve as a reliable and

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valid manifestation of the healing relationship as the face-to-face
encounter.

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• However, technology creates moral and ethical dilemmas-their application

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more so. Ethics, a word difficult to describe is also known as moral
philosophy, and addresses questions about morality—that is, concepts
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such as good and evil, right and wrong, virtue and vice, justice etc. Their
implications and place in evolving technology are interesting aspects,
especially in a field that so closely involves human beings directly.
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Confidentiality and the Law

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• This is a very important part of patient-doctor relationship and understood
with a lot of difficulty by people who are not doctors or who have not

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faced a situation where their intimate secrets as revealed to doctors have
been revealed. It is this feeling that engenders trust and may help the

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doctor in reaching a diagnosis and thereby help his patient-a societal safety
valve that caters to a human being's cry in an hour of need.

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• Confidentiality is commonly applied to conversations between doctors and
patients. Legal protections prevent physicians from revealing certain
discussions with patients, even under oath in court. However, it only

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applies to secrets shared between physician and patient during the course
of providing medical care.
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• The rule dates back to at least the Hippocratic Oath, which reads:
Whatever, in connection with my professional service, or not in connection
with it, I see or hear, in the life of men, which ought not to be spoken of
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abroad, I will not divulge, as reckoning that all such should be kept secret.
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• Traditionally, medical ethics has viewed the duty of confidentiality as a
relatively non-negotiable tenet of medical practice and has evolved to a
state where a doctor is supposed to maintain 'absolute confidentiality in all
he knows about his patient' even after the patient’s death. How this shall

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be maintained in the era of medical documentation remains a moot
question. Though various hospitals have evolved assorted guidelines and

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means to protect patient confidentiality, it still remains a difficult and
expensive task and may be a difficult proposition, especially in third world

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countries. How secure is information transmitted over open lines is still left
for technology to answer.

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• Interstate and intercountry telemedicine raises other licensure questions,
such as whether telephysicians practicing medicine in one state need a
license in the remote state? Is the information revealed in one state
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confidential in another state? There are states and countries with different
laws. For example, abortion may be legal in one state or country but illegal
in another. Would this information divulged to the doctor during
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consultation and legal in one state make the individual liable for
prosecution in another?
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The Electronic Medical Record: Privacy

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• Telemedicine demands that an electronic medical record of the patient be shared
across state lines. As among the network partners, who will have access to extract

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relevant network information, who is the ultimate custodian of the medical
record and who is responsible for ensuring the patient's privacy? Through

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legislation or through accreditation the reliability and standardisation of data and
the protection of the electronic medical record requires to be regulated.

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• The legal risks relating to the disclosure of inaccurate or confidential medical
information are significant. Such disclosure may result in defamation claims by

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the patient whose record is disclosed . Moreover, if case records are accidentally
disclosed and a patient who is suffering from tuberculosis is accidentally labelled
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as a malignancy may make a world of a difference in terms of employment and
rehabilitation. An individual who is HIV positive may suffer social ostracism if his
status is accidentally revealed. This becomes more pertinent in an era when the
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media is more interested in sensationalism of news than pragmatism. Therefore,
patients' consent to disclosure of information is a very important part of the
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agreement between the doctor or his institution and the patient.

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Malpractice Liability

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Healthcare systems owe a duty to the patients in their facilities. They

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have to prevent the harm negligently caused to the patients by them,
their employees, and agents. However, casual conversations by doctors

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over the phone, when patients are seeking advice come under this

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purview, a lot of times. Doctors may advice on the phone more out of
sympathy, but even this comes under legal ambit and the doctor may

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still be liable to malpractice. Therefore, it may pay to be careful,
especially when advising in life-threatening situations.
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Clinical Guidelines

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• The host may construct and track significant clinical practice pathways,
protocols, or guidelines depending on the extent to which it desires to

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make its physicians attractive to payers. Legally, two issues emerge. First,

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what is the liability of the host who will develop and implement the
guidelines? Second, what is the scope of provider liability for following

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imprudent guidelines or for not following effective guidelines?
• The host in our example may construct and apply guidelines to increase

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efficiency and decrease costs. To the extent that the guidelines track the
generally accepted standard of care in the community the institution
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developing guidelines has minimal risk. The institution accepting another's
guidelines must be careful to consistently implement the guidelines. Not
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following the guidelines set forth by a hospital may result in malpractice
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liability.
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The Patient-Doctor Relationship

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• The doctor-patient relationship is one of the most complex interpersonal
relationships, in that it involves individuals who are not on the same level, it

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has not been sought by both individuals, it is emotionally loaded and it
requires close mutual co-operation towards a shared goal. A well-managed

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clinical interview lays the grounds for a good doctor-patient relationship which
in turn leads to further advantages. Where a direct telemedicine consultation

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is sought by the patient, it would be better if it takes place when the doctor
has an existing professional relationship with the patient, or has adequate
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knowledge of the problem at hand, so that the doctor will be able to exercise
proper and justifiable clinical judgment.
• In an emergency, such judgments may have to be based on less than complete
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information, but in these instances the danger to the health of the patient will
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be the determinant factor in providing advice or treatment.

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Consent to Treatment

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• The concept of consent comes from the ethical issue of respect for
autonomy, individual integrity and self determination. The term

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'consent' means voluntary agreement, compliance, or permission.

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Section 13 of the Indian Contract Act lays down that two or more
persons are said to consent when they agree upon the same thing in

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the same sense (meeting of the minds)

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Risks Due to Technology

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• Given the sensitive nature of healthcare information, and the high degree
of dependence of health professionals on reliable records, the issues of
integrity, security, privacy, and confidentiality are of particular significance

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and must be clearly and effectively addressed by health and health-related
organisations and professionals. Two factors make the matter a subject of

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great significance: the intrinsically sensitive nature of patient data; and the
growing use of network computing, particularly the Internet, for healthcare

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information processing.
• The growth of off-site processing and storage of electronic health records

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by application services providers (ASPs) adds a new dimension to those
issues. Maintaining and safeguarding the integrity and physical protection
of data and systems, privacy and confidentiality of individual health
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information, quality of content, and the protection of consumers and
online health industry's commercial interests against unethical practices,
are the areas of greatest concern in the implementation and use of
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Internet and other interactive applications in health and healthcareiv .
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The Unique Challenges of Telemedicine

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Several features of telemedicine are capable of generating novel or complex
liability questions. Simultaneously acting as both enabler and destabiliser. Because

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it enables care delivery in a manner that transcends the long-established limits of
time, distance and institutional barriers, telemedicine challenges and undermines

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traditional norms and thereby changes: "the way that healthcare professionals
think of themselves and their work …" where information was previously

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departmentalised or compartmentalised in the future it will be available both
inside organisations and across them"
• Creating new ways of interacting with a patient - Reliance upon technological

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mediators to establish virtual "contact" raises questions about the steps required
to identify and overcome the qualitative deficiencies generated by the absence of
"hands on" contact.
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• Redefining existing roles and relationships between professionals - New models
of therapeutic, diagnostic and consultative interaction made possible by the
technology potentially generates legal issues regarding the identification of roles
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and allocation of responsibilities between parties and the steps required to
accommodate the new communications settings.
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• Ignoring/Transcending Borders - The technology permits interactions, in
real time or through "store and forward" technologies, between a wide
range of caregivers in different places at different times and from unrelated

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organisations.
• Involving More ‘Players’ - Not only does telemedicine potentially entail the

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simultaneous involvement of two or more practitioners, but it is
increasingly likely to involve allied health and "in-house" technical support

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personnel. In addition, there will be reliance upon the external entities
responsible for manufacturing, supplying and maintaining the necessary

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ICT. The increased number of "protagonists" is likely to generate more
complex and protracted litigation, not only because of the increased
number of potential defendants, but also because of the prospects for
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generating "product liability" claims as well as or instead of "medical
negligence" claims.
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History and Evolution of

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Telemedicine

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History and Evolution

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• A glance at any article or book on telemedicine reveals so many
different version of the history of the technique and different dates

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for the same event.

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• Telemedicine was not invented as a well defined discipline with
specialised instrumentation and protocols

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• Clinicians simply appropriated and began to use new technology
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developed for other purposes as they become available.
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Main Phases of Telemedicine Development

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Development Phase Approximate Timescale

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1. Telegraphy and

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telephony 1840s-1920s

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2. Radio 1920s onwards (main

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technology until 1950s)

3. .re
Television/Space Technologies 1950s onwards (main
technology until 1980s)
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4. Digital Technologies 1990/2000

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• Telegraphy used during the American Civil War to send casualty lists

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and order supplies. Later it has been replaced as a mean of long
distance communication following Marconi’s invention of the radio –
telegraph in 1897.

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• Radio Phase – In 1920s and 1930s saw the introduction of several

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radio-medical services.

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• In one or another these services continue in operation to the present
day.

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• The most celebrated example is the Italian International Radio
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Medicine Centre which began in 1935 and had assisted over 42,000
patients.
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• Television Phase – The next phase of development is coincided the

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widespread availability of black and white television in the 1950s.
• A closed-circuit television service began in 1955

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• The ability to visualise patient’s condition rather than rely on an audio
description greatly enhanced the diagnosis and the confidence of

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those engaged in treatment.

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• In 1964, the Nebraska Psychiatric Institute developed a two-way link
with Norfolk State Hospital, 112 miles away, with further extensions

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in 1971.
• The links were for education and consultations.
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• This is an example for telepsychiatry.
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• In 1957, a 20 year collaboration between the US Public Health Service

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and the National Aeronautics and Space Administration (NASA).
• The project, Space Technology Applied to Rural Papago Advanced

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Health Care (STARPAHC), sought to provide medical care to rural

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communities of Papago via the transmission of electrocardiography
and X-rays to centres staffed by specialists.

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• This is an example of teleradiology.

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• This is the first use of telemedicine to extend the reach of
conventional services to rural or disadvantaged communities.
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• The Logan International Airport facility setup in 1967 to provide

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occupational health services to airport employees and to deliver
emergency care and medical attention to the air passengers.

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• A microwave link connected the airport clinic with Massachusetts
General Hospital and along the Nebraska Institute.

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• The project was one of the earliest instances of physician – patient

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interaction using two-way interactive television.

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• Satellite Communication – In the 1970s, the first batch of commercial

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communication satellites become available, and the clinicians quickly
saw the opportunities to extend the scope of telemedicine.

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• Alaska Satellite Biomedical Demonstration program to improve village
healthcare.

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• Various Canadian projects to serve remote areas based upon NASA’s

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Hermes satellite, launched in 1976.
• North-West Telemedicine Project set up in Queensland, Australia. This

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project was designed to serve rural communities.
• NASA SpaceBridge to Armenia setup in the wake of the terrible
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earthquake in December 1988. SpaceBridge allowed video, voice and
facsimile consultations to take place between specialist centres in the
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USA and a medical centre in Yerevan, Armenia.
• This was the first truly international telemedicine program.
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1906: ECG Transmission

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Einthoven, the father of electrocardiography, first investigated on ECG
transmission over telephone lines in 1906. He wrote an article “Le
telecardiogramme” at the Archives Internationales Physiologi.

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1920s: Help for ships

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Telemedicine dates back to the 1920s. During this time, radios were used to
link physicians standing watch at shore stations to assist ships at sea that had
medical emergencies.

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1924: The first exposition of Telecare
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Perhaps it was the cover showed below of "Radio News" magazine from April
1924. The article even includes a spoof electronic circuit diagram which
combined all the gadgets of the day into this latest marvel!
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1964: Telepsychiatry
The Nebraska Psychiatric Institute was one of the first facilities in the country
to have closed-circuit television in 1955. In 1971 the Nebraska Medical

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Center was linked with the Omaha Veterans Administration Hospital and VA
facilities in two other towns.

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1967: Massachusetts General Hospital
This station was established in 1967 to provide occupational health services

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to airport employees and to deliver emergency care and medical attention to
travelers.
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1970s: Satellite telemedicine
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Via ATS-6 satellites. In these projects, paramedics in remote Alaskan and
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Canadian villages were linked with hospitals in distant towns or cities

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The Role of NASA in Early Development

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The National Aeronautics and Space Administration (NASA) played an
important part in the early development of telemedicine NASA's efforts in

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telemedicine began in the early 1960s when humans began flying in space.

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Physiological parameters were telemetered from both the spacecraft and
the space suits during missions. These early efforts and the enhancement in

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communications satellites fostered the development of telemedicine and
many of the medical devices in the delivery of health care today.

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NASA provided much of the technology and funding for early telemedicine
demonstrations, two of which are the Space Technology Applied to Rural
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Papago Advanced Health Care (STARPAHC) and the Nebraska Medical Centre.
There were several pioneering efforts not only in the US, but all over the
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world.
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OMD 553

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TELEHEALTH TECHNOLOGY

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LTPC
3003

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OBJECTIVES:
The student should be made to:

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Learn the key principles for telemedicine and health.

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• Understand telemedical technology.
• Know telemedical standards, mobile telemedicine and it applications

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UNIT I TELEMEDICINE AND HEALTH 9

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History and Evolution of telemedicine, Organs of telemedicine, Global and Indian scenario, Ethical
and legal aspects of Telemedicine - Confidentiality, Social and legal issues, Safety and regulatory

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issues, Advances in Telemedicine.
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UNIT II TELEMEDICAL TECHNOLOGY 9
Principles of Multimedia - Text, Audio, Video, data, Data communications and networks, PSTN,
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POTS, ANT, ISDN, Internet, Air/ wireless communications Communication infrastructure for
telemedicine – LAN and WAN technology. Satellite communication, Mobile communication.
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UNIT III TELEMEDICAL STANDARDS 9
Data Security and Standards: Encryption, Cryptography, Mechanisms of encryption, phases of
Encryption. Protocols: TCP/IP, ISO-OSI, Standards to followed DICOM, HL7, H. 320 series Video
Conferencing, Security and confidentiality of medical records, Cyber laws related to telemedicine

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UNIT IV MOBILE TELEMEDICINE 9

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Tele radiology: Image Acquisition system Display system, Tele pathology, Medical information
storage and management for telemedicine- patient information, medical history, test reports,

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medical images, Hospital information system

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UNIT V TELEMEDICAL APPLICATIONS 9
Telemedicine – health education and self care. · Introduction to robotics surgery, Telesurgery.
Telecardiology, Teleoncology, Telemedicine in neurosciences, Business aspects - Project planning
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and costing, Usage of telemedicine.

TOTAL : 45 PERIODS
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OUTCOMES:
At the end of the course, the student should be able to:

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Apply multimedia technologies in telemedicine.

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• Explain Protocols behind encryption techniques for secure
transmission of data.

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• Apply telehealth in healthcare.

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TEXT BOOK:

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1. Norris, A.C. “Essentials of Telemedicine and Telecare”, Wiley, 2002

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REFERENCES:
1. Wootton, R., Craig, J., Patterson, V. (Eds.), “Introduction to Telemedicine. Royal

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Society of Medicine” Press Ltd, Taylor & Francis 2006
2. O'Carroll, P.W., Yasnoff, W.A., Ward, E., Ripp, L.H., Martin, E.L. (Eds), “Public Health

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Informatics and Information Systems”, Springer, 2003.
3. Ferrer-Roca, O., Sosa - Iudicissa, M. (Eds.), Handbook of Telemedicine. IOS Press

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(Studies in Health Technology and Informatics, Volume 54, 2002.
4. Simpson, W. Video over IP. A practical guide to technology and applications. Focal
Press Elsevier, 2006.
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5. Bemmel, J.H. van, Musen, M.A. (Eds.) Handbook of Medical Informatics. Heidelberg,
Germany: Springer, 1997 6. Mohan Bansal " Medical Informatics", Tata McGraw-Hill,
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2004.
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Introduction

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Telehealth is the use of digital information
and communication technologies, such as

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computers and mobile devices, to access
health care services remotely and manage

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your health care. These may
be technologies you use from home or that
your doctor uses to improve or support

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health care services

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TELEMEDICINE

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• Medicine at a distance

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• The transfer of electronic medical data from one location to another

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• Telemedicine is the use of telecommunications to provide medical

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information and services
• Telemedicine utilizes information and telecommunication technology

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to transfer medical information for diagnosis, therapy and education

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DEFENITIONS

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TELEMEDICINE
Telemedicine is the use of information and communication

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technologies to transfer medical information for the delivery of clinical

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and educational services
TELEHEALTH

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Telehealth is the use of information and communication
technologies to transfer healthcare information for the delivery of

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clinical, administrative and educational services.
TELECARE .re
Telecare is the use of information and communication
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technologies to transfer medical information for the delivery of clinical
services to patients in their place of domicile.
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• Access, equity, quality, and cost-effectiveness are key issues facing
health care in both developed and less economically developed
countries.

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• Modern information and communication technologies (ICTs), such as

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computers, the Internet, and cell phones, are revolutionizing how

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individuals communicate with each other, seek and exchange
information, and enriching their lives.

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• These technologies have great potential to help address
contemporary global health problems.
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• Telehealth: The delivery of health care, health education, and health
information services via remote technologies.

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• Telemedicine, a term coined in the 1970s, which literally means
“healing at a distance”, signifies the use of ICT to improve patient

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outcomes by increasing access to care and medical information.

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Difference Between Telehealth and Telemedicine

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• Telehealth is different from telemedicine because it refers to a broader

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scope of remote healthcare services than telemedicine. While
telemedicine refers specifically to remote clinical services, telehealth

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can refer to remote non-clinical services, such as provide training,

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administrative meetings, and continuing medical education, in
addition to clinical services.

jin
• Telehealth and telemedicine are two different fields that play different
roles in healthcare organizations. While telehealth is commonly used to
.re
describe a wide range of education, management, diagnosis and other
related health care fields, telemedicine is referring to traditional
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monitoring and clinical diagnosis delivered at a distance by technology.
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What is Telemedicine?

om
• Oxford’s telemedicine definition is “the remote diagnosis and

.c
treatment of patients by means of telecommunications technology.”

ul
• Telemedicine encompasses the use of technologies and
telecommunication systems to administer healthcare to patients who

pa
are geographically separated from providers.
• For example, a radiologist may read and interpret the imaging results

jin
for a patient in a different county whose hospital does not currently
.re
have a radiologist on staff.
• Or a physician may conduct an urgent-care consultation via video for a
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non-life-threatening condition.
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Telehealth includes different services such as:
• Home health

.c
• Counselling

ul
• Dentistry
• Occupational and physical therapy

pa
• Disaster management

jin
• Chronic disease management and monitoring
• Professional and consumer education
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Telehealth categories

.c
• Live video

ul
• Store-and-forward

pa
• Remote patient monitoring (RPM)
• Mobile health

jin
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Live video

om
• This telehealth service provides live, two-way interaction between a
caregiver or a person and a health care provider by using technology

.c
for audiovisual telecommunications.

ul
• This service type may serve as a substitute for an in-person encounter

pa
and it is also referred to as “real-time”.
• Live video telehealth service can be used both for consultative and

jin
diagnostic as well as treatment services.

.re
• In many circumstances, this can be a real life saving technology.
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Store-and-forward
• The telehealth service consists in the transmission of recorded health

.c
history to a practitioner through a secure electronic communications
system.

ul
• The specialist typically uses the information in order to render a

pa
service outside the live or real-time interaction or to evaluate the
case.

jin
• This service involves communication tools like secure email and
provides access to the data after it has been collected.
.re
• Even when the board-certified specialists are limited in a certain
community, store and forward technology can help access specialty
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care.
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Remote patient monitoring
• This telehealth service consists in the collection of medical and

.c
personal health data from an individual via technologies for electronic
communication.

ul
• Data collected is then remotely transmitted to a provider in a

pa
different location for use in various health care services and related
support.

jin
• The remote patient monitoring type of service allows providers to
track healthcare data even after a patient has been released to a care
.re
facility or home. This way the readmission rates are reduced.
• Remote patient monitoring can help individuals remain in their
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community and home, reducing the need to physically visit the health
care providers’ office.
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Mobile health

.c
• This is a telehealth service that provides public care practice, health
care, and education via mobile communication devices such as

ul
computers, tablets, cell phones, and PDAs.

pa
• Mobile health applications range from wide scale alerts about disease
outbreaks to targeted text messages that promote healthy behaviour.

jin
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Technologies Involved

.c
• Medical Instrumentation

ul
Sensing Bio-medical Signals,
Medical Imaging, Measurement of Physical

pa
Parameters e.g. Body Temperature, Pressure etc.
• Telecommunication Technology

jin
Trans-receiver on different communication
channels and network such as, on wired network,
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wireless medium etc.
• Information Technology
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Information representation, storage,
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retrieval, processing, and presentation.

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Benefits of Telemedicine

.c
• Better access to healthcare

ul
• Access to better healthcare

pa
• Improved communication between carers
• Easier and better continuing education

jin
• Better access to information
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• Better resource utilization
• Reduced costs
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Limitations of Telemedicine

.c
• Poor patient-carer relationships

ul
• Poor relationships between healthcare professionals

pa
• Impersonal technology
• Organisational disruption

jin
• Additional training needs
.re
• Difficult protocol development
• Uncertain quality of health information
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• Low rates of utilization
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Barriers to progress

.c
• Telecommunication and infrastructure standards

ul
• Cost effectiveness

pa
• National policy and strategy
• Ethical and legal aspects

jin
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TELEMEDICINE APPLICATIONS

om
• Emergency Health Care

.c
• Video Consulting

ul
• Telecardiology
Telemedicine as applied by cardiologist is called telecardiology.

pa
• Telepathology
• Teledermatology

jin
• Teleophthamology
• Teleoncology
• Telepsychiatry
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• Teledentistry
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• Distance Leaning
• Medical education and the transfer ofmedical data.

.c
• Medical care delivery, diagnosis, consultation and treatment at a

ul
distance.

pa
• Nursing homes or retirement centers.
• Home monitoring for patients

jin
• Health care in the after of disasters.
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.c
ul
Networking in Telemedicine

pa
jin
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• A network is a collection of distributed and intelligent machines that

om
share data, information and hardware resources through inter-
connected lines of communication

.c
• Network connectivity can also be used to connect and facilitate

ul
diagnostic data exchange between various telemedicine system inside

pa
and outside of a hospital.

jin
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There are four design considerations in classifying networks are

om
1. Physical distance
The actual physical distance over which the network is expected
to operate

.c
2. Bandwidth

ul
The amount of data that can be transmitted over a channel

pa
3. Network topology
The physical interconnection of network nodes

jin
star, loop, ring, bus, trees
4.Protocols .re
Set of rules adopted by the network which govern data
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transmission
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Network configurations

.c
• Point to point connection

ul
• Local Area Networks (LANs)

pa
• Metropolitan Area Networks (MANs)
• Wide Area Networks (WANs)

jin
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Point to point connection

om
• Image/data transmission
• Sending and receiving stations are directly connected to each other

.c
by a dedicated network link using a single wire or fibre-optic cable

ul
pa
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Local Area Networks (LANs)

om
.c
ul
pa
jin
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Local Area Networks (LANs) www.rejinpaul.com

om
• Provides networking capability to a group of a computers in an office
or hospital or campus or a home

.c
• Enables high speed data exchange capability between two systems

ul
and facilitates diagnostic data exchange between various
telemedicine stations inside a medical facility

pa
• Hardware requirement for implementing LAN is a Network Interface
Card (NIC)

jin
• The standard governing the LAN connectivity is IEEE 802.3, with a
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minimum speed of 10Mbps.
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Metropolitan Area Networks (MANs)

.c
ul
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Metropolitan Area Networks (MANs)

.c
• Covers the area of a single city

ul
• Larger than LAN

pa
• Does not exceed 100km
• Comprises a combination of different hardware and transmission

jin
media

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Wide Area Networks (WANs)

om
.c
ul
pa
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• WAN can be visualised as a network consisting of many LANs

om
interconnected to create a super network
• Internet is the world’s largest and most prevalent WAN

.c
• WAN connectivity depends on the availability of WAN infrastructure
in the geographical area

ul
WAN link connection

pa
(i) Dial up connection : on demand

jin
(ii) Dedicated connection : it is a leased line connection, which is
available full time exclusively to the user
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(iii) Switched network : these network provide shared line or
bandwidth to several users
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WAN Technologies

om
• A set of switches and routers are interconnected to form a wide area

.c
network

ul
Packet Switching Technology

pa
allows users to share common carrier resources so that the
carrier can make more efficient use of its infrastructure

jin
Circuit Switching Technology
.re
allows data connections to be established when needed and
then terminated when communication is completed
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2 types of Packet Switching
(i) X.25

.c
(ii) Frame relay

ul
X.25

pa
• Based on the use of ordinary analog telephone line
• Full-duplex communication

jin
• X.25 is an ITU-T standard suite of protocols

.re
• The protocols work at Layers 1 to 3 of the OSI model, i.e., physical
layer, data link layer and network layer
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• Each X.25 packet contains upto 128 bytes of data
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Frame relay

om
• Fast packet switching technology
• Frame relay transfers variable-length packets upto 4KB in size and

.c
56Kbps

ul
• Data is put in a variable size units called a frame and leaves any

pa
necessary error correction upto end points, which speeds up overall
data transmission

jin
• It operates at the data link layer of the OSI model
• Frame relay networks can provide a high data connection up to 1.544
Mbps .re
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OSI MODEL

om
.c
ul
pa
jin
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.c
The Internet as

ul
Communication Medium

pa
jin
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• Internet is quite suitable for telemedicine purposes

om
• accessing the internet by using a modem and an ordinary telephone
network

.c
• The internet makes use of web services for storing data which

ul
subsequently gets distributed to the users on demand
• A client-server architecture approach is used for telemedicine

pa
• Virtual Private Network (VPN) can be established between two sites

jin
which can provide a private and secure connection.

.re
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Advantages
• Universal availability

.c
• Everyone can access the desired site on the internet at any time at

ul
any place

pa
• Clinician can have access to patient data from home through the
internet

jin
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Examples
• A radiologist may be looking for more information while examining an

.c
X-ray image before rendering some clinical advise

ul
• A consultant can use internet to advise a junior doctor working in the

pa
emergency department on a particular problem

jin
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Broadband service

.c
• It is referred to as a service that provides for high-speed transfer of
data, voice and video over the internet in a reliable manner

ul
• Broadband speed required for a particular application depends upon

pa
technology, geography or location and some other parameters.

jin
• Broadband networks can be accessed through a variety of wired and
wireless services
.re
• Each of them has its own specific and unique advantages in terms of
speed, affordability and reliability.
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Benefits of broadband in telemedicine

.c
Broadband has

ul
• enabled the introduction and expansion of telemedicine services

pa
• provided a number of life-enhancing and potentially life saving
benefits.

jin
• helped in reducing the cost of healthcare
• Improved the quality of healthcare
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Expansion of healthcare provisions

om
• the healthcare services are extended to remote and under-served
segments of a country

.c
• Quality healthcare services are provided to all geographic locations
Easier telehome care

ul
• Facilitated the establishment of efficient and effective in-home diagnostic,

pa
monitoring and treatment services
• Beneficial for senior citizens who will be able to avail of more and better

jin
care at home
Better healthcare administration
.re
• Greatly helped in streamlining healthcare administration especially in
managing electronic health records, resulting in higher efficiency in back-
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office operations and consequently leading to substantial cost savings.
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Broadband Technologies
• Fixed line broadband technologies

.c
(i) cable modem

ul
(ii)xDSL (Digital Subscriber Line)

pa
(iii) power line
• Wireless broadband technologies

jin
(i) Wi-Fi
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(ii) Mobile Wireless
(iii) LET (Long Term Evolution)
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(iv) Satellite
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.c
ul
Satellite Communication

pa
jin
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• Satellite technology has been widely used in implementing

om
telemedicine projects to remote and isolated areas

.c
• There is a lack of reliable terrestrial communication facility in remote
and isolated areas. Therefore, satellite communication is the best

ul
means of communication for telemedicine in remote areas

pa
• Satellite communication provides connectivity to remote areas of the

jin
earth and mobile vehicles such as ships and aircrafts

.re
• Satellite communication has been widely used to implement
telemedicine projects in military units and in ships in the seas and
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oceans
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• A satellite is any physical object that revolves around the earth in a

om
known orbit at a known height.
• The path followed by the satellite is called its orbit

.c
• There are two types of satellites

ul
• Natural satellites
• Artificial satellites

pa
• Moon is a natural satellite of earth
• All planets in the solar system revolves around the sun . So all

jin
planets are satellites of sun
.re
• There are several number of artificial satellites. The greatest number
of artificial satellites are used for communication purposes.
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om
• A communication satellite system has two segments
Space Segment i.e., Satellite

.c
Ground Segment, i.e., earth station

ul
Space segment consists of three units

pa
Fuel system

jin
Telemetry control system
Transponders
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.c
ul
pa
jin
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.c
ul
pa
jin
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.c
ul
pa
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• In space, satellites are physically separated from each other. Different
satellites can be distinguished by the beam width of the antenna

.c
• Communication satellites are placed at geostationary orbits, which
means they are motion less with respect to earth.

ul
• The orbit is located at 36000km above the equator

pa
• As per ITU guidelines, there has to be a separation of 2 degrees
between 2 satellites so as to avoid interference in their operations

jin
• The maximum number of satellites which can operate in a
.re
geostationary orbit is 180
• The number of transponders determines the capacity of the satellite
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.c
ul
Transmission of Still Images

pa
jin
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Various types of digitising methods

.c
• Digitising analog images

ul
• Computer generated images

pa
• Photographic imaging
• Image scanning

jin
• Video photography
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Digitising analog images
• Images stored in the traditional film are converted into digital format

.c
• CCD and laser based scanners are used for digitising

ul
pa
Computer generated images
• Electronically generated images are directly stored in the computer

jin
• For example ultrasound, CT and MRI images
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Photographic imaging

om
• Sometimes a low cost digital camera image may sufficient for some
applications.

.c
• Eg. Skin lesion

ul
pa
Image scanning
• An inexpensive flatbed scanner can be used to digitise graphics,

jin
photographs or charts such as ECG, X-ray film etc.

Video photography
.re
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• Another method to capture still images is by using a video camera.
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Image Compression

.c
• To reduce the amount of memory required for storage
• To reduce transmission time

ul
• Compression is applied by eliminating gaps, empty fields, similar

pa
coloured areas and redundancies within an image

jin
• Data compression is also refers to as data encoding

Compression ratio .re

The ratio of the size of a compressed file to the original uncompressed
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file.
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Data compression for transmission

om
• The capacity of the communication channel can be increased by
several folds by reducing the size of the data intended for

.c
transmission

ul
• Data compression in telemedicine is to squeeze the data so that it
requires less bandwidth on a data transmission channel

pa
• Data compression aims at reducing redundancy in communicated
data, thus increasing effective data density

jin
• Minimize the data to be transmitted
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Data compression for storage

om
• If a file is compressed to half of its original size, the capacity of the
storage medium will get doubled.

.c
ul
Types of data compression

pa
• Lossless compression – it is completely reversible
• Lossy compression – it results in a loss of information

jin
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Lossless compression

om
• Data is compressed without any loss of information in the compression
process

.c
• The data after decompression is exactly the same as it was before
compression

ul
• Text files are stored employing lossless compression

pa
jin
Commonly used lossless algorithms are
Arithmetic coding
JPEG 2000
Run length coding
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Lempel-Ziv-Welch (LZW) algorithm
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Huffman coding
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Lossy compression

om
• Lossy compression works on the assumption that data does not have
to be stored perfectly and some loss of information is acceptable

.c
• Much information from audio, video and image can be discarded.

ul
• In this case, a compressed and decompressed image is likely to

pa
appear different from the original one.
• Lossy compression is widely used in video conferencing

jin
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Standards for still images

.c
• In telemedicine, three families of still image coding standards are
commonly used

ul
• JPEG

pa
• DICOM
• PC based still image compression (Eg: GIF)

jin
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JPEG – Joint Photographic Experts Group

om
• Mostly used for compression
• Lossy and loss-less compression modes are available

.c
• Used for full colour images and grayscale images only, not suitable for

ul
video or moving images

pa
• JPEG compression is based on Discrete Cosine Transform (DCT)
technique

jin
• Improved version of JPEG is JPEG 2000 which uses wavelet technology
.re
• JPEG 2000 gives about 20% better compression than traditional JPEG
• Widely used in teleradiology
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Advantage

om
• It is widely available on most of the computer platforms

.c
Limitation

ul
• It compresses the entire image employing the same compression

pa
factor.

jin
• It is not possible to store the selected regions of interest to give
better quality image.
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GIF-Graphics Interchange Format

om
• It is a bit map colour raster image format which allows pictures upto
256 distinct colours

.c
• It has been widely used in the World Wide Web

ul
• GIF was developed to reduce the time taken in transferring image

pa
over a network connection
• It is a loss less data compression algorithm

jin
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DICOM
• Digital Imaging and COmmunications in Medicine

.c
• It is an international standard related to the exchange, storage and
communication of medical images and other related data

ul
• The DICOM standard covers both the formats to be used for storage

pa
digital medical images and related digital data, and the protocols to
be adopted to implement several communication services which are

jin
useful in the medical imaging workflow.
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.c
Transmission of video

ul
pa
jin
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Video images are required for

om
• Interactive visual communication

.c
ul
• Proper medical diagnosis

pa
jin
• Evaluation of condition of patient

.re
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• Digital video is a sequence of still images

om
• 30 frames per second
• Videos require a lot of memory

.c
• Transmitting a raw video image is not efficient and, therefore, video
compression techniques have to be employed

ul
• Video compression basically involves removal of pixels carrying

pa
redundant or repetitive information from each frame.

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Video Compression

.c
Four popular methods

ul
• Discrete cosine transform(DCT)

pa
• Vector quantisation(VQ)
• Fractal compression(FC)

jin
• Wavelet transform(WT)
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Discrete cosine transform(DCT)

.c
• Lossy compression algorithm

ul
• Sampling an image at regular intervals and analysing the frequency
component present in the sample

pa
• Frequencies that do not affect the image are discarded

jin
• The data is then represented as a series of cosine waves
• DCT forms the basis of standards such as JPEG, MPEG, H.261 and
H.263 .re
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Vector quantisation

.c
• Lossy compression

ul
• It process an array of data rather than individual values

pa
• It compresses the redundant data

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Fractal compression

.c
• FC is a form of VQ

ul
• Lossy compression

pa
• Compression is done by identifying similar sections of an image, then
applies a fractional algorithm for generating the sections.

jin
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Wavelet Transform

.c
• The wavelet transform is similar to the Fourier transform

ul
• FT takes a signal in time domain and represents it in frequency
domain

pa
• In wavelet transform, the signal is analysed into their frequency

jin
components by varying scale at which the component frequencies are
analysed.
.re
• Wavelets produce functions and operations that are small, which
make them well suited for applications such as data compression and
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noise reduction in signals
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Video Compression Standards
MPEG- Moving Picture Experts Group

.c
ITU - International Telecommunication Union

ul
pa
MPEG

jin
• set up in 1988 to formulate standards that define data formatting,
data rates and compression techniques
.re
• Uses the intra-frame and inter-frame compression methods and DCT
• Several MPEG standards have been developed - MPEG-1, MPEG-2,
w
MPEG-4, MPEG-7, MPEG-21
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MPEG-1

om
• ISO/IEC 11172 international standard

.c
• Compression of moving pictures and audio

ul
• It is designed for a transmission speed upto 1.5 Mbps.

pa
• Widely used standard for video on internet
• Level 3 of MPEG-1, MP3, is a widely used standard for digital

jin
compression of audio signals
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MPEG-2

om
• ISO/IEC 13818 international standard

.c
• Designed for compression between 1.5 and 15Mbps

ul
• Widely used standard for the compression and transmission of digital
broadcast television

pa
• Aslo implemented in digital television set top boxes and DVDs

jin
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MPEG-4

.c
• ISO/IEC 14496 international standard

ul
• Widely used standard for multimedia and web compression

pa
applications
• Significantly higher compression ratios

jin
• Very low bit rate audio-visual coding system
.re
• Ability to encode mixed media data (video, audio, speech)
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MPEG-7

om
• ISO/IEC 15938 international standard
• multimedia content description standard (not a compression

.c
standard)

ul
• Includes standards for information on content, its manipulation and

pa
filtering, and the integrity and security aspects of the content
MPEG-21

jin
• ISO/IEC 21000 international standard
.re
• Rights Expression Language
• standard for the management of restrictions for digital content usage.
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• Designed to communicate machine readable license information
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ITU Standards
Standards for Telecommunications and Information Communication

.c
Technology

ul
H.120

pa
• Designed for video telephony over digital lines
• Bit rates 2Mbps

jin
H.261
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• Video compression standard
• data rates are multiples of 64 Kbps
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• it is part of ITU H.320 series of videoconferencing standards
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H.261

om
• Video compression standard
• Designed for low bit rate and low latency requirements

.c
• Bit rates below 1 Mbps

ul
• Most popular video compression algorithm

pa
jin
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.c
Transmission of audio

ul
pa
jin
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• Audio is used for conversation and medical diagnosis in telemedicine
• Electronic stethoscope and Doppler ultrasound produce audio

.c
information

ul
• Frequency response of Electronic stethoscope – 20Hz to 2kHz

pa
Doppler ultrasound - 100Hz to 10kHz
• Audio signals are first digitised and compressed before combining

jin
with digital video and other information
.re
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Audio Compression
ITU G.711

.c
• Pulse code modulation (PCM) of voice frequencies

ul
• Sampling frequency 8 kHz

pa
• 64 kbit/s bitrate (8 kHz sampling frequency × 8 bits per sample)
• Speech bandwidth 300–3400 Hz.

jin
ITU G.711
• Adaptive differential pulse-code modulation (ADPCM)
.re
• Sampling frequency 16 kHz
w
• 64 kbit/s bitrate
w

• speech bandwidth of 50–7000 Hz

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ITU G.723.1

om
• Dual rate speech coder for multimedia communications transmitting
at 5.3 and 6.3 kbit/s

.c
• Pulse code modulation (PCM) of voice frequencies

ul
• Sampling frequency 8 kHz

pa
• Speech bandwidth 300–3400 Hz.
ITU G.728

jin
• Linear predictive coding (LPC)
.re
• Sampling frequency 8 kHz
• 16 kbit/s bitrate
w
• Speech bandwidth 300–3400 Hz.
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MPEG-1 Audio standard
• Audio compression technology

.c
• Sampling rate- 32kHz, 44.1kHz, or 48kHz

ul
• 3 levels of audio compression – layer 1, layer 2 and layer3
• Layer 3 is MP3

pa
• Modified discrete cosine transform (MDCT) is used

jin
.re
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om
.c
ul
Data Communication and Networks

pa
jin
.re
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• POTS – Plain Old Telephone Service

om
• ISDN – Integrated Service Digital Network
• ANT – Adaptive Network Topology

.c
• PSTN – Public Switch Telephone Network

ul
pa
jin
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POTS – Plain Old Telephone Service

om
• Based on public telephone network

.c
• Exchange of simple medical and administrative information

ul
• Easy and cheap

pa
• 30-40% tele-consulatations
• Inefficient system and very prone to frequency breakdown and noise

jin
• Not a reliable service for long-distance communication
.re
• For telemedicine, a line modem is used to provide interface two
points using telephone lines
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• With POTS, digital signals can be transmitted upto about 56Kbps

om
• This bandwidth is sufficient for still image transmission
• This method is widely used in applications such as teledermatology

.c
and telepathology

ul
pa
jin
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ISDN – Integrated Service Digital Network

om
• Developed to increase the capacity of an analog network and to
improve the transmission quality and the range of services offered

.c
without the need for physically replacing the entire network

ul
• This system allows simultaneous transmission of voice, data and
signalling using end to end digital connectivity

pa
• ISDN can operate over copper based telecommunication network, but
provides higher data sped and better quality than analog transmission

jin
• Noise, distortion, echoes and crosstalk are not present
.re
• Good choice for tetemedicine applications due to higher bandwidth
in the network
w
• High speed, better security and good quality
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Configuration of ISDN

om
Two basic types of ISDN sevices
(i) Basic Rate Interface (BRI)

.c
(ii) Primary Rate Interface (PRI)

ul
ISDN services are composed of B and D channels

pa
B or ‘Bearer’ Channel
• To carry voice and information

jin
• Minimum bandwidth required is 64Kbps
D or ‘Data Channel’.re
• To carry signalling and control information
w
• Handles signals at 16Kbps or 64Kbps
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Basic Rate Interface (BRI)

om
• BRI comprises of two B channels each of which provides a bandwidth
of 64Kbps and one D channel with a bandwidth of 16Kbps.

.c
• Together, this configuration is referred to as (2B+D), and provides a

ul
total bandwidth of 144Kbps.

pa
Line termination (LT) – network end of the line
Network termination (NT) – user end of the network

jin
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Primary Rate Interface (PRI)

om
• Higher bandwidth
• The number of B channels required would depend on the bandwidth

.c
necessary for a particular location
• It has a D channel with 64Kbps

ul
There are two configurations E1 and T1

pa
E1
• In Europe and Australia

jin
• 32 channels at the speed of 64Kbps
.re
• Data rate 2.048 Mbps
• Out of 32 channels. One channel is dedicated for signalling while the
w
other channel is for controlling
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T1

om
• In north America and Japan
• 24 digital channels

.c
• Data rate is 1.544 Mbps

ul
pa
jin
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Advantages of ISDN

om
Speed
• ISDN allows simultaneous operation of multiple digital channels through

.c
the conventional phone wiring system used for analog signals

ul
• It supports an uncompressed data transfer speed of 128Kbps
• Time taken by an ISDN line to begin communication is typically half that of

pa
an analog line.
Multiple devices

jin
• Allows multiple devices to share single line
Signaling
.re
• Exchange of additional information between involved points in the network
that sets up, controls and terminates each telephone call.
w
• It does not take any bandwidth from the data channels.
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ANT – Adaptive Network Topology

om
• Ultra-low power, short range wireless technology

.c
• ANT allows short-range wireless communication in point to point or
more complex network topologies

ul
• ANT uses the 2.4 GHz ISM band

pa
• It works efficiently in embedded systems that are based on peer – to
– peer or star network topology

jin
• ANT uses the very short duty cycle technique and deep-sleep modes
.re
to ensure very low power consumption.
w
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om
.c
Wireless technologies for

ul
telemedicine

pa
jin
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• Healthcare providers are taking great advantage of the explosion of

om
wireless technologies
• Wireless Standard – industrial Scientific and Medical (ISM) band

.c
• The ISM band frequency spectrum can be used by anyone without a

ul
license

pa
• The product developed and in use must comply with the rules that
govern this part of the frequency spectrum

jin
• Other wireless standards such as Zig Bee/IEEE 802.15.4, Bluetooth,
BLE and ANT are widely used in telemedicine
.re
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Wi-Fi – Wireless Local Area Network
• Uses radio waves to provide wireless high-speed internet and

.c
network connectivity

ul
• IEEE 802.11x standard – family of standard governs wireless
connectivity for fixed, portable and moving stations within a local

pa
area
• It operates at the lowest two layers of the OSI model, physical layer

jin
and data link layer
.re
• Operates in ISM bands (2.4GHz, 5GHz)
• Speed up to 54Mbps
w
• Allow data, voice and video applications
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• Work on the principle of Carrier Sense Multiple Access/Collision

om
Avoidance(CSMA/CA) to access the media
• Coverage area ranges from 50 – 300m

.c
• WLAN provide the much needed mobility to the users as there is no

ul
need for physical cable connection to a local area network

pa
• WLAN provide mobility, flexibility and high productivity for both care
givers and patients

jin
• The corner stone of any wireless network is an access point (AP)
.re
• AP acts as an adaptor to send/receive the wireless signal from our
wireless network
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• For connectivity to an access point and joining a wireless network, the

om
computers and devices must have wireless network adaptors
• The most popular versions include 802.11a/b/g/n standards

.c
• 802.11a operates at 5 GHz, whereas all other operate at 2.4 GHz

ul
• WLAN 802.11 standards have security protocol that have been

pa
developed to provide the same level of security to that of a wired LAN
1. Wired Equivalent Privacy (WEP)

jin
2. Wi-Fi Protected Access (WPA)
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Wired Equivalent Privacy (WEP)
• Data transmitted over WLAN is protected by encrypting it

.c
Wi-Fi Protected Access (WPA)

ul
• This protocol provides improved data encryption based on temporal
key integrity protocol

pa
• This protocol addresses the weakness of WEP by including a per-
packet mixing function, a message integrity check, an extended

jin
initialisation vector and a re-keying mechanism
.re
• It also provides user authentication
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.c
ul
pa
jin
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.c
ul
pa
jin
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Worldwide interoperability for Microwave

om
Access (WiMAX)

.c
• Wireless broadband technology

ul
• Delivers Wi-Fi connectivity over a much greater operating range

pa
• Provides a point-to-multipoint last-mile broadband wireless access
solution

jin
• WiMAX as “a standards-based technology enabling the delivery of last
mile wireless broadband access as an alternative to cable and DSL”.
.re
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• Two tyes of WiMAX
1. Line-Of-Sight (LOS)

.c
2. Non-Line-Of-Sight (NLOS)

ul
• The LOS WiMAX systems are designed to provide point-to-point

pa
connectivity
• NLOS WiMAX systems allow point-to-multipoint applications

jin
• WiMAX is a family of wireless communications standards based on
.re
the IEEE 802.16 standard
• The objective of WiMAX system is to deliver capacity of up to 75Mbps
w
per channel for fixed and portable access applications in a typical cell
radius of 3-9 km.
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.c
ul
pa
jin
.re
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.c
ul
DICOM

pa
jin
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• DICOM – Digital Imaging and COmmunication in Medicine

om
• An international standard related to the exchange, storage and
communication of digital medical images and other related digital

.c
data.

ul
• The DICOM standard covers both the formats to be used for storage
of digital medical images and related digital data, and the protocols to

pa
be adopted to implement several communication services which are
useful in the medical imaging workflow.

jin
• Developed by American College of Radiology (ACR) and National
.re
Electrical Manufactures Association (NEMA)
• Computer tomography, nuclear medicine imaging, digital subtraction
w
angiography, and magnetic resonance imaging are digital images and
can be directly converted to DICOM format
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Objectives of DICOM
• To have a general standard so that it can be applied to the entire
range of medical images encountered in the healthcare field

.c
• To standardise communication of digital image information

ul
regardless of manufacturer of imaging equipment

pa
• To facilitate the development and expansion of PACS that can
interface with other systems

jin
• To promote creation of diagnostic information data bases that can
be accessed by a wide variety of devices and users distributed
geographically .re
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• DICOM enable avoidance of different standards for various types of

om
medical images facilitating storing and transmitting electronic patient
records that include images also

.c
• DICOM facilitates integration of various items of hardware such as
work stations, servers and network hardware

ul
• The different machines supplied by various vendors come with

pa
DICOM conformance statements indicating the DICOM classes they
are designed to support

jin
• DICOM facilitates different image acquisition devices and imaging
workstations to be connected into a common imaging information
infrastructure .re
• Storage technologies - Picture Archiving and Communication Systems
w
(PACS), Hospital Information System (HIS) and Radiological
Information System (RIS)
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• The DICOM standard addresses the semantics of commands and

om
associated data
it provides standards on how devices are expected to respond to

.c
commands and associated data

ul
• The DICOM standard explicitly defines the conformance
requirements for implementing the standard

pa
• The DICOM standard does not require network interface units to

jin
operate in a network environment
• The DICOM standard provides support for future application as it is
.re
structured to accommodate the introduction of new devices
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• Besides facilitating the transfer of images, the DICOM standard also
includes transfer of associated data and information relating to the
patient, the health provider and the device

.c
• The DICOM version 3 facilitates transfer and interchange of

ul
waveforms such as ECG, EEG, EMG etc.

pa
• DICOM files consists of a header with standardised as well as free-
form fields and a body of image data

jin
• The header contains the patient details such as name, scan type,
dimensions of the image etc.
.re
• A single DICOM file can contain one or more images, allowing storage
of large volume of information
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• The network interface for communicating between various systems is

om
generally TCP/IP which facilitates transfer data from the data
scanners, CT, MRI, etc. or between telemedicine systems
• In DICOM, grayscale images are 16 bits per pixel and true colour

.c
images are 24 bits per pixel plus 8 bits per pixel for intensity

ul
information

pa
• DICOM is based on OSI reference model

jin
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.c
ul
Encryption

pa
jin
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Encryption And Decryption

om
• Encryption Terminology

.c
• Encryption: A process of encoding a message or information in such a way that

ul
only authorized parties can access it and those who are not authorized cannot
• Cryptosystem: A combination of encryption and

pa
decryption methods
• Cleartext or Plaintext: Information before encryption

jin
• Cipher text: Information in encrypted form
.re
• One-way cipher: Encryption system that cannot be easily reversed (used for
passwords)
w
• Decryption: Reversing encryption process
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om
To ensure the privacy of messages sent over a network between a source and destination, the text can be encrypted.
• Cryptography - study of methods to encrypt text.
• Cryptanalysis - study of how to decode an encrypted text.

.c
ul
pa
Conventional or single key encryption - a simple algorithm is used to transform the text

jin
• substitution cipher - each letter of the alphabet is substituted with a different letter or symbol.
• Ceasar's method - replace every letter in the alphabet with the letter 3 away
A-> D
B->E
C->F
.re
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...
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X->A
Y->B
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Z->C
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Symmetric/ Private Key Encryption

om
• Uses a single number key to encode and decode the data. Both the sender
and receiver must know the key

.c
• DES (Data Encryption Standard) is the most widely used standard for
symmetric encryption

ul
• Because each sender and receiver would require a different key, this type of

pa
encryption is basically used by government entities
• It is rarely used for e-commerce transactions over the Internet
• Requires a secure way to get the key to both parties

jin
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Asymmetric / Public Key Encryption

om
• Uses two numeric keys
• The public key is available to anyone wishing to communicate securely with the key’s owner

.c
• The private key is available only to the owner

• Both keys are able to encrypt and decrypt each other’s messages

ul
• Anyone who has a public key can encrypt information but cannot decrypt it.
Only the person who has the corresponding private key can decrypt the

pa
information.
• Example: encode by raising to 5th power and moding result with 91

jin
Decode by raising to 29th power mod 91
325= 2 (mod 91) and 229=32 (mod 91)

.re
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ENCRYPTION ALGORITHMS

.c
DES (DATA ENCRYPTION STANDARD)

ul
pa
AES (ADVANCED ENCRYPTION STANDARD)

jin
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Data Encryption Standard (DES)

om
.c
• symmetric-key method
of data encryption.

ul
• Block cipher: 64 bits at

pa
a time

jin
• Initial permutation
rearranges 64 bits (no
.re
cryptographic effect)
• Encoding is in 16 rounds
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ONE ROUND

om
.c
• 64 bits divided into left,
right halves

ul
• Right half goes through

pa
function f, mixed with
key

jin
• Right half added to left
half .re
• Halves swapped (except
w
in last round)
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om
.c
• Expand right side
from 32 to 48 bits

ul
(some get reused)

pa
• Add 48 bits of key
(chosen by

jin
schedule)
.re
• S-boxes: each set of
6 bits reduced to 4
w
• P-box permutes 32
bits
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Inverse

.c
• Equations for round i:

ul
Li = Ri −1
Ri = Li −1 ⊕ f (Ri −1 )

pa
• In other words:

jin
Ri −1 = Li
Li −1 = Ri ⊕ f (Li )
.re
w
• So decryption is the same as encryption
w

• Last round, no swap: really is the same

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om
AES ( ADVANCED ENCRYPTION STANDARD)
• symmetric key cryptography

.c
• AES comprises three block ciphers: AES-128, AES-192 and AES-256

ul
• There are 10 rounds for 128-bit keys, 12 rounds for 192-bit keys and 14

pa
rounds for 256-bit keys
• The first transformation in the AES encryption cipher is substitution of data

jin
using a substitution table
• The second transformation shifts data rows
.re
• The third mixes columns
w
• The last transformation is a simple exclusive or (XOR) operation performed
w

on each column using a different part of the encryption key

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om
.c
AES

ul
ENCRYPTION

pa
PRECESS

jin
.re
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.c
AES

ul
structure

pa
jin
.re
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SUBSTITUTE BYTES

.c
a simple substitution of each byte

ul
uses one table of 16x16 bytes containing a permutation of all 256 8-bit
values

pa
each byte of state is replaced by byte indexed by row (left 4-bits) &
column (right 4-bits)

jin
 eg. byte {95} is replaced by byte in row 9 column 5

.re
which has value {2A}
S-box constructed using defined transformation of values in GF(28)
w
designed to be resistant to all known attacks
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om
SUBSTITUTE BYTES

.c
ul
pa
jin
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SHIFT ROWS

.c
a circular byte shift in each

ul
 1st row is unchanged
2nd row does 1 byte circular shift to left

pa


 3rd row does 2 byte circular shift to left

4th row does 3 byte circular shift to left

jin


decrypt inverts using shifts to right

between the columns

.re
since state is processed by columns, this step permutes bytes
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SHIFT ROWS

.c
ul
pa
jin
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om
MIX COLUMNS

.c
each column is processed separately

ul
each byte is replaced by a value dependent on all 4 bytes in the
column

pa
effectively a matrix multiplication in GF(28) using prime poly m(x)
=x8+x4+x3+x+1

jin
.re
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MIX COLUMNS

.c
ul
pa
jin
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ADD ROUND KEY

.c
XOR state with 128-bits of the round key

ul
again processed by column (though effectively a series of

pa
byte operations)
inverse for decryption identical

jin
 since XOR own inverse, with reversed keys


.re
designed to be as simple as possible
a form of Vernam cipher on expanded key
w
 requires other stages for complexity / security
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ADD ROUND KEY

.c
ul
pa
jin
.re
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om
.c
ul
Health Level 7 (HL7)

pa
jin
.re
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• HL7 is an American National Standards Institute (ANSI) Standard for

om
exchange of healthcare data between computer systems.
• The term “Level 7” refers to the top layer (Level 7, Application Level)

.c
of the OSI of the International Organisation for standardisation (ISO)
for healthcare environment

ul
• The application level defines the data to be exchanged, the timings of

pa
its interchange and the communication of certain errors to the
application

jin
• HL7 is recognised as the most commonly used standard in the world
.re
as it supports clinical practice and its management, delivery and
evaluation of health services
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• HL7 is a comprehensive protocol for electronic data exchange and
defines transmission transactions for a variety of functions such as
patient registration, insurance, billing and orders.

.c
• A protocol is also applied for communicating results of laboratory

ul
tests, physiological parameters, imaging reports, physician
observations, nurse’s notes, diet and pharmacy orders and

pa
inventory/supply status.

jin
• It also defines communication protocol between two independent
applications
.re
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• HL7 protocol comprises of grammar and vocabulary, which has been

om
standardised to allow clinical data to be shared amongst all
healthcare systems

.c
• All systems following the HL7 specifications are able to communicate

ul
easily with other by using the HL7 messaging protocol as a standard,
without the need for information conversion

pa
jin
HL7 standards are grouped into the following reference categories
Section 1: Primary standards
•
.re
most popular standard for system integrations, inter-operability
and compliance
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Section 2: Foundational Standards

om
• Defines the fundamental tools and building blocks used to build the
standards and the technology infrastructure

.c
Section 3: Clinical and administrative domains

ul
• Messaging and document standard for clinical specialities and groups

pa
are included in this section
Section 4: EHR Profile

jin
• These standards provide functional model and profile that enable
management of electronic health records
.re
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Section 5: Implementation guides
• For implementation guides and/or to support documents created to
be used in conjunction with an existing standard

.c
Section 6: Rules and references

ul
• Technical specifications, programming structures and guidelines for

pa
software and standards development
Section 7: Education and awareness

jin
• Standards for trial use providing helpful resources and tools to further
.re
supplement understanding and adoption of HL7 standards
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• HL7 defines how information is packaged and communicated from

om
one party to another
• It sets the language, structure and data types necessary for seamless
integration amongst various systems

.c
• Either of the following approaches may ne used, for exchange of data

ul
from one system to another

pa
(i) Transport Control Protocol/ Internet Protocol (TCP/IP)
(ii) File transfer protocol (FTP)

jin
.re
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HL versions

om
• The evolution of HL standard is a continuous process
• Over a period of time, various versions of standard have been

.c
developed and are in use

ul
• The HL7 Version 2 Messaging Standard-Application Protocol for

pa
Electronic Data Exchange in Healthcare environments has emerged as
the workhorse of data exchange in healthcare.

jin
• It is the most widely implemented standard for healthcare
information in the world
.re
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om
HL Version 2.4
• It incorporated conformance query profiles and included messages

.c
for laboratory automation, application management and personal
management

ul
pa
HL Version 3

jin
• Version 3 has been built around a single object model, the Reference
Information Model (RIM)
.re
• RIM expresses the data content needed in a specific clinical or
administrative context
w
• HL7 Version 3 encodes messages using XML
w
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om
.c
ul
Video Conferencing Standards

pa
jin
.re
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• H.3xx are the video conferencing standards recommended by ITU

om
• This includes protocols for coding video/audio, multiplexing, signalling
and control

.c
• H.320, H.321,H.323, H.324 are the commonly used video

ul
conferencing standards

pa
• H.320 – standard for video conferencing over ISDN. It is also used in
dedicated networks such as T1 and satellite based networks

jin
• H.321 – standards for video conferencing over ATM and B-ISDN
• H.323 – video conferencing over Internet Protocol (IP) and voice over
IP (VOIP) .re
• H.324 - standards for video conferencing over general(dial-up)
w
telephone networks (POTS)
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om
H.320 (ISDN)
• H.320 is a suite of standards for running multimedia

.c
(audio/video/data) over ISDN –based networks

ul
• H.320 suite include the following coding standards
Video : H.261, H.263, H.264

pa
Audio : G.711, G.722, G.722.1, G.728

jin
Data : T.120
Control : H.221, H.231, H.242, H.243
.re
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om
.c
ul
pa
jin
.re
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H.323 (Internet, LAN)

om
• Multimedia communications over LANs

.c
• Multimedia communications over packet networks

ul
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• H.323 standard includes
(I) when used for LAN conferencing

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Video : H.264, H.263, H.261

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Audio : G.711, G.722, G.723, G.728, G.729
Data : H.239, T.120

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Control : H.225, H.245

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(ii) when used for internet conferencing

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Video : H.264, H.263, H.261
Audio : G.722, G.723, G.728
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Data : H.239, T.120
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Control : H.225, H.245

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• One of the primary goal in the development of the H.323 standard is

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interoperability with other multimedia services networks
• Interoperability is achieved through the use of gateway

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• A gateway performs any network or signalling translation required for
interoperability

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• H.323 has four optional network components when used with video

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conferencing system
• Terminals (end points)

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• H.323 gate keepers
H.320 gateway
•
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Multipoint control units (MCUs)
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Terminals
• Terminals are the client endpoints on the LAN that provide real-time
two way communications

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• A public IP address is required for the terminal

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• The minimum setup for a single H.323 endpoint is an ADSL Router

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with a public IP address
• All terminals must support voice communication minimum of G.711

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• The terminal may support T.120 for data sharing and minimum H.261
QCIF for video .re
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Gate keepers

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• Provides services such as address translation and network access
control for H.323 terminals, gateways and MCUs

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• Gatekeeper oversees authentication, authorisation, telephone

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directory and PBX services as well as call control and routing

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• Bandwidth management, accounting and dial plans
• Prevent network congestion by controlling terminal access

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Gateway
• Provide connectivity between H.323 terminals and other H.3xx
terminals operating on their respective networks

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• Provide transcoding services as well as system control and signalling

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with the other H.3xx terminals

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Multipoint Control Units (MCU)
• MCU control interactive conferencing among three or more terminals

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within a session
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H.324 (plain Old Telephone Service)
• Establishes low bandwidth multiplexing / control protocol

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• It includes the following standards

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Video: H.263

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Audio : G.723
Data: T.120

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Medical information storage and

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management for telemedicine

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Maturity and adoption models
A number of models have been developed to help assess or describe

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the current level of information technology adoption in the health

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sector.

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• Capability Maturity Model
• Enterprise Architecture

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• Australian National eHealth Interoperability Maturity Model
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• Interoperability Maturity Model levels
• The HIMSS EMR Adoption Model
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Capability Maturity Model
• The Capability Maturity Model (CMM) was originally defined for

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software development by Carnegie Mellon University and is useful
for assessing health information systems.

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• Five levels are defined along the model’s continuum.

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• Predictability, effectiveness, and control of an organization’s

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software processes are believed to improve as the organization
moves up these five levels.
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• Level 1. Initial (chaotic, ad hoc, individual heroics) – the starting point
for use of a new process.

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• Level 2. Repeatable – the process is able to be used repeatedly, with
roughly repeatable outcomes.

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• Level 3. Defined – the process is defined/confirmed as a standard

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business process
• Level 4. Managed – the process is managed according to the metrics

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described in level 3, that is, data collection and analysis.
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• Level 5. Optimized – process management includes deliberate
process optimization/improvement.
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Enterprise Architecture

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• In order to implement the Enterprise Architecture process, the

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organization must first establish the preliminary framework and
principles, a requirements management process, and governance.

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• After the requirements and governance are established, EA focuses

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on a continuous cycle of improvements.
• The steps of this process are: architecture vision, business

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architecture, information system architecture, technology
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architecture, opportunities and solutions, migration planning,
implementation governance, and architecture change management.
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• This continuous cycle is the key to successful information system
improvement in this process.
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Australian National eHealth Interoperability

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Maturity Model

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• Individual health information must follow the patient as s/he receive
services from various providers.

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• This requires data interoperability which is the key to effective use of

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health information.

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• The Australian National eHealth Transition Authority has defined an
Interoperability Maturity Model that identifies increasing capability
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for data interoperability.
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Interoperability Maturity Model levels

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• Initial: There is an early awareness of eHealth interoperability
requirements and characteristics and perhaps some initial eHealth

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interoperability solutions adopted, typically localized within certain

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clinical or administrative domains.
• Managed: An organization will begin accomplishing some

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interoperability goals, such as the adoption of specific eHealth
standards while gaining an early, shared understanding of data
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services or internal processes as well as initial governance established
to ensure repetition of earlier successes.
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• Defined: An organization has defined a set of guidelines for the
adoption of eHealth standards for data, services and processes,
according to the lessons learnt from previous maturity levels.

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Communication standards for interaction with internal and

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external partners are established, facilitating a shared understanding
across technical and semantic issues.

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• Measured: An organization has established processes for appraising

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and measuring eHealth interoperability.
• Optimized: The organization has implemented processes to support
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continuous interoperability improvements, driven by feedback from
monitored processes.
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The HIMSS EMR Adoption Model

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• This model relates to the management of patient information.
• It was developed by the United States based Healthcare Information

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and Management Systems Society (HIMSS).

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• The HIMSS Electronic Medical Record Adoption Model describes the
stages from 0 to 7 of EMR adoption within organizations

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• It starts with laboratory, radiology and pharmacy and progresses to
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document imaging, clinical documentation and protocols, and
medications.
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• Stage 0: Some clinical automation may be present, but all three of the

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major ancillary department systems for laboratory, pharmacy, and
radiology are not implemented.

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• Stage 1: All three of the major ancillary clinical systems (pharmacy,
laboratory, radiology) are installed.

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• Stage 2: Major ancillary clinical systems feed data to a clinical document

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repository (CDR) that provides physicians access to results.
• Stage 3: Clinical documentation (e.g. vital signs, flow sheets) is required.

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• Stage 4: This includes a computerized provider order entry (CPOE) along
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with the second level of clinical decision support capabilities related to
evidence-based medicine protocols.
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• Stage 5: The closed loop medication administration environment is

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fully implemented in at least one patient care service area.
• Stage 6: Full physician documentation/charting (using structured

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templates) is implemented for at least one patient care service area.

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• Stage 7: The hospital has a paperless EMR environment. Clinical

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information can be readily shared via electronic transactions or
exchange of electronic records with all entities.

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ul
TELEPATHOLOGY

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• Pathology is the medical speciality concerned with the study of the

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nature and causes of diseases through the examination of tissues,
cells and organs

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• The diagnosis is made by the pathologist by examining cell and tissues
sections using a microscope

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• In telepathology, the diagnosis is made remotely by studying the

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transferred microscopic images of tissue samples

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• The applications of telepathology include
i. Tele diagnosis
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ii. Distant learning and teaching
iii. Remote image and data processing
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iv. Quality control
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Types of Telepathology services

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In telepathology, there are two ways to obtain teleconsultation

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i. Diagnosis from still microscopical image

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ii. Dynamic system using robotic video microscopy

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Categories of Telepathology

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i. Static Telepathology

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ii. Dynamic Telepathology

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iii. Hybrid Telepathology

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Static Telepathology

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• In a static telepathology system, a small number of slide images of
interest are selected by the doctor

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• Images are captured in a digital format on an image frame grabber

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board and sent to the specialist located at a remote site

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• Image transfer is usually done by email or by a File Transfer Protocol
(FTP)

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• Store and forward mode

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• Simple and inexpensive
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Dynamic Telepathology

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• In a dynamic system, a real-time live images of a specimen are transmitted
from the microscope to the monitor at a remote site.

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• The pathologist at the remote site can control the microscope operation
while viewing and uses the necessary tools to select diagnostic fields by

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moving the microscope stage and adjust focus, magnification with change

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of objectives and illumination on the microscope
• This is achieved by using a telerobotic system which can be remotely

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operated by the telepathologist
• A phone link is normally used to have a two-way voice communication
between participants.re
• In the absence of a telerobotic system, a telepathologist assistant is given
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instructions to operate the microscope in a particular way at the remote
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location, by following telephonic instructions from the telepathologist

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• The microscope functions are controlled through USB or an RS 232

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serial port
• For the client software, terminal client software is used, which

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transfers the entire screen content of the server to the client

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• Dynamic telepathology is performed between centres using the same
operating system

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• The minimum bandwidth requirement is 128 Kbps for satisfactory
image transfer

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Hybrid System
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• A hybrid system can be formed by combining the efficient bandwidth
utilisation and reliable transmission of static system with the real-
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time control and imaging of the dynamic system
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Equipment for Telepathology

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A telepathology system consists of

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i. Telepathology workstation – pathologists receives images and audio
information from remote areas

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It consists of a computer with graphics card and a colour monitor

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and software to manage images, including image acquisition and data
file storage

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ii. Image management system – image acquisition, database file
storage
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iii. High resolution video camera with resolution better than 1000 X
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750 pixels to capture images of pathologic specimens
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iv. Telecommunication setup to transmit images to the remote site for
transfer of data, images and audio in telepathology

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The most important telecommunication networks used for
telepathology are ISDN, T1/T3 line, ATM and broadband internet

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pa
• The quality of the image in a real-time interactive system depends
upon the quality of the camera, the image acquisition hardware, the

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speed of the processor of the host computer and the chosen
telecommunication network
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• A 3-chip camera is usually preferred for telepathology
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ul
TELERADIOLOGY

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• Teleradiology is the electronic transmission of radiologic images from one
location to another for the purpose of interpretation and/or consultation.

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• Images are sent through digital, computer-assisted transmission, typically over

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standard telephone lines, Wide Area Network (WAN) or a Local Area Network
(LAN).

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• Through teleradiology, images (X-rays, CT scans, MRIs, ultra sound images

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etc) can be sent to another part of the hospital or around the world.

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• Teleradiology was the first widely developed implementation of telemedicine
and, therefore, it is presently considered as a mature technology.
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Goals of teleradiology
• Providing consultative and inter relative radiologic services

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• Providing timely availability of radiologic interpretation in emergent

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clinical care situations

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• Enhancing continuing educational opportunities for practicing
radiologists

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A common method of image transfer is to use a CODEC (coder-
decoder) which transforms analog images to digital information and
compress the data
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At the remote site, another CODEC is used to decompress the signal
and to convert it into analog form for real-time viewing on a monitor
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Steps involved in Teleradiology

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i. Producing digital image
• when the output of the imaging device is not available in the digital

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form, the first step lies in digitising a radiology film

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• A film digitiser is used to convert radiographs (x-ray films) into digital

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form
ii. Interfacing patient information

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• Providing the health record information required to correctly identify
the patient and his complete medical history to the radiologist
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iii. Compressing images and other data
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• Certain pixels in the digitized images are dropped to decrease
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iv. Transmission of images

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• The images are transferred from one site to another over telephone
lines, ISDN, T1, Eathernet/LAN, satellite or coaxial lines etc.

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• The choice of communication method would depend upon the size of
the file and bandwidth of line of transmission suitable for

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teleradiology system

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v. Reconstruction of images
• This is done at viewing site for display evaluation and review

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Components of Teleradiology system

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Three basic components

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i. An image sending station

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ii. A transmission network
iii. A receiving / image review station

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Image sending station

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• The sending station has a telemedicine workstation, film digitisation
equipment and a modem

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• Film digitisers can be categorised into three types

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i. Camera digitiser

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ii. Charge Coupled Device
iii. Laser scanner digitisers

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• All the three types of film digitisers perform the same basic function
of converting the x-ray image on the film to the digital signal
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• The digitisers differs in terms of quality of image resolution, ease of
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• The three most important specifications for a teleradiology sending
station are resolution, compression and transmission speed.
Image resolution

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• Resolution is the ability of an imaging system to differentiate among

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closely spaced objects

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Compression
• Data compression is used to increase transmission speed and reduce

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storage requirements for a particular size of data file
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eg: JPEG, DICOM, TIFF, GIF, PNG
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Transmission (modem) speed

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• A modem is the interface unit between the image digitiser and the
transmission network

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• The speed of modem is expressed in bits per second or baud rate

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In teleradiology sending station should have very high resolution, little
or no compression and very high transmission speed.

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Transmission network

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• There are several communication modalities available for data
transfer from one telemedicine station to another

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• The images can be transmitted by means of conventional modes such

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as ISDN, ATM, satellite, T1 communication links.
• The most commonly used transmission networks currently in use for

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teleradiology are those provided by the internet service providers.
• The network utilises both wire and fibre optics as a medium of

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transmission
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• Image transmission time is directional proportional to the file size of
the digital image
• With the advent of wireless technology, the data transfer speed of 72
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Receiving/image review station

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A receiving station consists of
i. Network interface which is a modem

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ii. Personal computer with hard disc drive as storage medium

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iii. One or two display monitors

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iv. Hard copy printer

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The following factors should be kept in view while setting up a

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teleradiology system

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i. All equipment should be DICOM standard compatible

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ii. The HL7 standard should be used for health data communication
iii. Teleradiology work must meet current standards for digital

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radiology

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iv. Transmission and reception of images should be according to all
applicable state and federal laws including Health Insurance and
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Portability and Accountability Act(HIPPA)
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Types of teleradiology systems

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There are three types of teleradiology systems

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i. On-call: used for after-hour “on-call” applications

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ii. Off-site: “off-site” systems are set up mostly by radiology specialists
and hospitals to establish central database with a view to expand

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interpretation network.
iii. In-hospital: In-hospital systems are meant to be used to transfer
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images within the same facility over a LAN.
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BUSINESS ASPECTS OF

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TELEMEDICINE

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10 Critical Steps for a Successful Telemedicine Program

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1. Establish a Vision
2. Building a Long Term Financial Plan

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3. Create a Convenient and Effective Work Environment

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4. Mainstream Telemedicine into the Standard Care Process

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5. Plan and Assure Effective Training
6. Make Sure You Have a Full Time Coordinator(s) and an Effective

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Leader and Cheer- leader
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7. A Project Plan = Manageable Milestones = Reasonable Expectations
8. Horizontal vs. Vertical Implementation
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9. Good Marketing is Critical
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10. Publish or Perish?

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Establish a Vision

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Successful telemedicine programs consistently presented

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• a clear vision of the program
• a clear vision of how the telemedicine program contributes to the overall

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vision of the organization

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• identify and understand the strategic and tactical objectives and vision of
your overall organization.
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• know what objective the organization wants to use telemedicine to
accomplish. This depends on the business model or motivations the
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organization is pursu- ing.
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Building a Long Term Financial Plan
Give clear short and long-term financial goals.

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Examples include:

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• If it is a revenue model, show clear revenue management.

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• If it is a cost saving model, show your benchmark and a method to clearly
measure the savings.

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• If it is a strategic model, show a way to measure strategic contribution or
result.
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Develop a financial plan and define the measurements that will be used to
drive achievement of the plan’s goals. Make sure these measurements are
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understood and at least tacitly accepted by manage-ment.
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Create a Convenient and Effective Work Environment

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• Telemedicine must be available where it is needed.
• The equipment must be available at or very near to where care is provided

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and where the consul ng physician works.
Examples:

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• An effective sending room: A standard exam room with the same exam

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table, tools and sup- plies that a typical exam room would have. In an
environment similar and familiar with non- telemedicine care.
• An effective consulting (receiving) room: Located in or very close to the

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consultant’s work- place. A small quiet room with all the required tools
close at hand. If the consul ng physician uses a PC or text to access
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reference in their normal course of work, these tools should be in the
room. If a fax machine might be used to provide more information, it
should be included in the room as well. (The best consulting room is often
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the consulting physician’s office.)
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Mainstream Telemedicine into the Standard Care Process
• Delivering care with telemedicine should be the same as delivering
care without telemedicine.

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• A simple rule to keep in mind is that “The more change that must be

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adopted the higher the likelihood of failure.”

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• Standard protocols for the use of equipment, for examination and for
documentation should be written for each medical specialty.

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• The protocols should follow the standard protocol used in non-
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telemedicine as much as possible.
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Plan and Assure Effective Training
Training is critical. Successful programs plan for it and deliver well-de
ned training in layers. Timing is often as important as content. The

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basic foundation for training should include:

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• Communication technology

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• Clinical technology
• Diagnostic device user training for both send and receive sites

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• Work flow and protocols of care and procedures for use of devices
Documentation
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• Troubleshooting and access to product and technical support
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Make Sure You Have a Full Time Coordinator(s) and an Effective
Leader and Cheer- leader

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• Almost all successful programs have a full me coordinator responsible
for day-to-day operations and available to support and serve the

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users.

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• That person must: schedule session; make sure everything is working
properly; encourage users; see and address issues; make sure people

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are using the system and removing obstacles for those who are not.
• This person must have the necessary skills, authority and esteem to
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manage the program, y cover for the program participants, inform
management and assure that the program is properly marketed.
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A Project Plan = Manageable Milestones = Reasonable Expectations
When a project plan is well de ned and clearly understood, both

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expectations and responsibilities can be properly set.
• Warning #1: Do not over plan and paralyze the project.

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Warning #2: A project plan is a tool. Do not use it as an offensive

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weapon.
• Warning #3: Keep management simple. Involve as many parties as

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possible. Keep the number of committees to a minimum and give
them a fixed objective and duration. Give the manager of the
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program one master whenever possible.
• Warning #4: Set reasonable milestones in the plan and meet them
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Horizontal vs. Vertical Implementation
Horizontal Implementation - providing as many sites as possible with a

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very limited amount of capability in each site.
Vertical Implementation - start with very few sites with very extensive

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capability in each site.

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• neither strategy is successful

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• The successful strategy is a balanced approach. Establishing a limited
number of reasonably capable sites. This focuses management
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attention. It also keeps the audience manageable and focused. It
simplifies communication and support and maximizes the likelihood
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Good Marketing is Critical

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• A rule of thumb in business is that “the investment for marke ng and
sales of any product is usually equal to or greater than the cost of
developing the product or services.”

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• Good marketing starts with under- standing the needs and wants of

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your users and organization.

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• Do not get blinded by your own vision.
• Know what other groups want and how you might answer that need.

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• Know how others are measured. Understand why some people might resist.
• Build your message based on wants, needs, measurements and specific
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resistance. Claim success and set public expectations.
• Tell the world the good things you’ve done. Tell the world what is coming
next.
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• Give credit freely. It is an inexpensive but valuable currency.
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Publish or Perish?
• Programs that focus on presenting or publishing the results or status

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of their program (or some part of their program) at least once per
year appear to do significantly better than those that do not.

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• The act of publication, teaching and sharing your knowledge and

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expertise is very important in many ways.

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• Submit abstracts. Publish peer-reviewed articles. Present posters.
Involve members of your telemedicine team.
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• Do this at least once per year.
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The programs that succeed are the programs that manage change well by:
• Setting a clear vision
• Establishing goals and measurements

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• Providing a plan and a roadmap to success

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• Creating a good and effective work environment

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• Managing implementation and communication
• Minimizing disruption

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• Providing training and effective support

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• Providing good management, assistance and leadership
• Staying focused
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• Selling your program to others
• Publishing your results and accepting both outside criticism and recognition
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TELESURGERY

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• Telesurgery is basically surgery performed from a distance by an

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operating surgeon with direct, real-time visualisation of the operating
field

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• The surgeon is not physically present in the operating theatre but
operates with the help of a console located remotely from patient site

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• Still this is not widely used because of its complexity and relatively

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high cost in its implementation
• Telesurgery may be categorised as follows

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1. Telementoring
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2. Robot – assisted surgery
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Telementoring

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• Telementoring is a process wherein a specialist surgeon acts as a
preceptor for a remote, comparatively less experienced surgeon by
providing him guidance from a distance

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• The guidance can be on advanced or new technique and is generally

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provided by using videoconferencing technology

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• It involves real time observation and mentoring
• The level of interaction from the mentor can vary from case to case

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and it would be even verbal guidance while watching real time video
of the scene of the operation
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• The image is sent using a network of high data rate communication
with sufficient bandwidth to give a good picture quality at the
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• A bandwidth of 384Kbps is the minimum requirement to provide

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acceptable picture quality for accurate interpretation by the mentor
• Broadband internet service is widely used for telecommunication

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purposes

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Robot – Assisted Surgery

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• Preferred technique for performing precision surgery

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• High precision robots have recently become available with the
development of tiny sensors and actuators

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• Actuators can make movement in all three directions and make

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extremely small movements
• The basic function of an actuator is to translate the command given

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by the surgeon into a robot’s movement
• Robot surgery
.reintegrates telecommunication equipment,
networking, medical devices and robots to enable remote surgical
telecollaboration
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• In the robot controlled surgery, the surgeon does not perform the
surgery with his own hands, rather he gets it done with the help of
robotic arms under his directions

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• The surgeon console is suitably designed to display a full 3D high

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resolution view of the operating scene on a monitor screen.

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• The sensitive electronics and surgical arms of the surgical robot allow
the surgeon to maneuver precision movements

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Telepresence/Telerobotic Surgery

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• Telepresence surgery is a technique that allows a surgical procedure
to be performed on a patient located at a place which is physically
remote from the operating surgeon

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• This is achieved by providing the sensory illusion that the surgeon’s

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hand are indeed in direct contact with the patient undergoing surgery

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• By combining advanced technologies such as 3D imaging,
telerobotics, sensory devices and video transmission technologies,
the surgeon can get full sensory experience of conventional hands-on

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surgery
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• The system provides direct communication on auditory, visual and
tactile sensations including the force and pressure experienced while
making an incision
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• This enables the surgeon to perform the operation without much
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delay or problem
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Components of Telerobotic System

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• Sensors – sensing minute movement of surgeon’s hand in real-time
with precision

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• Cameras – should be capable of delivering high resolution clear
images of the patient without any kind of obstruction or instruction

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• Actuators – exactly replicate 3D hand movements as interpreted by

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the sensors without any delay. Accurate location capabilities with 3D
reconstruction model, robotics representation, stereotaxic and visual

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reality capability

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• Communication network – a fast communication network is required
to deliver multimedia data in both directions. It should be highly
reliable so as to ensure that it is free of transmission errors
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throughout the entire operating procedure
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TELECARDIOLOGY

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• Telecardiology is the transmission of cardiac data to a remote location

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from the patient site
• Telecardiology is the effort to merge technology with cardiology in

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order to provide the patient with proper and accurate medical advice
and medical care

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• Purpose is to make the necessary information available for the

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consulting cardiologist and other care givers as quickly and reliably as
possible

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• Telecardiology has been in use for a long time beginning with
telephones which has been used in transmitting heart and breath
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sounds for over 70 years
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• For telecardiology, transmission rates of 256Kbps or 384 Kbps are

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adequate and as such full T1(1.5Mbps) bandwidth or a broadband
connectivity for interactive video is preferable

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• Store and forward concept has been commonly used in
telecardiology applications

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• Data acquired from the patient with the use of investigating

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equipment and clinical protocols is stored in a computer in a specific
format

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• It is then sent to a consulting physician for interpretation, diagnosis,
confirmatory or second opinion
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• The patient data package consists of a multi-media file containing
patient history and physical examination data, ECG tracings, digital
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pictures, X-rays, streaming video clips and other imaging data sent
electronically
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Equipment for telecardiology

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(i) Personal computer / laptop computer

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(ii) Complete patient electronic health record

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(iii) Digital ECG recorder connected to the PC by serial port, equipped
with computerised diagnostic ECG interpretation software

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(iv) Digital stethoscope

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(v) Dedicated phone line with modem including mobile
communication facility
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(vi) Videoconferencing equipment
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(vii) Document camera
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TELE-ECHOCARDIOGRAPHY

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• The addition of echocardiographic examination to the clinical
assessment of a patient can significantly increase diagnostic accuracy,

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reduce unwarranted diagnostic and treatment referrals and facilitates

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the optimal utilisation of healthcare resources.
• This can provide diagnostic imaging information to healthcare

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providers independently from the location of specialist
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• This is generally done using video transmission techniques combined
with videoconferencing using high bandwidth transmission technique.
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Teleoncology

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• Access to quality cancer care is often unavailable not only in low- and

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middle-income countries but also in rural or remote areas of high-
income countries.

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• Teleoncology has the potential to enhance both access to and the
quality of clinical cancer care as well as education and training.

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• Systematic and effective communication between individuals at

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advanced oncology centers and those at remote or resource-poor
centers can improve cancer care and enhance opportunities for

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continuing clinical education.
• Therefore, disparities in cancer care can be reduced by the
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development of resources—human capital and telecommunication
infrastructure
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Technology Advantages Disadvantages

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Web conferencing Low cost Limited resolution of images
Wide availability Images cannot be manipulated
Participants may not see each
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other

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Videoconferencing Good image resolution Expensive
Images can be manipulated Requires maintenance
Participants can see each other

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Readily available
Can present/interview patients

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Supports image-intensive clinical case collaborations (diagnosis,
radiation/surgery planning, disease monitoring)
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Telesynergy A multimedia workstation integrates all components for collaborative Very expensive

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multidisciplinary teleoncology Requires ~ 20 ISDN channels
High image resolution Requires many peripheral
Transmits images from their primary sources components

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Allows image manipulation
Supports comprehensive multidisciplinary case review and discussion
Supports collaborative planning of radiation and surgery
Difficult to install
Requires intensive maintenance
Requires dedicated storage space
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Virtual telemicroscope Operator can control microscope without special hardware or Limited to pathology
software Expensive
Good image resolution Performance depends on the user’s
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computer
Robotic telesurgery Circumvents hand tremors Bulky equipment
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Supports fine surgical movements Very expensive

Requires special training
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TELENERUOLOGY

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• Teleneurology is the use of telecommunications to improve the
delivery of neurology services.

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• A wide range of telecommunications techniques may be used,
including the telephone, email, the Internet and videoconferencing.

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Teleneurology can improve access to specialist neurological services

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for patients all over the world.
• Teleneurology also deals with more specialized fields that are of

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interest to the neurological practitioner, such as neurophysiology and
neuroradiology.
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• An electroencephalograph (EEG) is an important investigative test in

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the field of neurology.
• A tele-EEG service in which EEGs could be reported remotely for

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analysis and advice.
• The tele-EEG service has become possible with the availability of

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modern EEG machines

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• EEG machines allow recorded EEG files to be stored in digital format,
compressed, transmitted securely and remotely on any PC with

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appropriate analysis software.
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• Tele-EEG is a solution to a shortage of specialist in clinical
neurophysiology
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