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Telemedicine Application in Surgery : Indian Experienceand
Update on Telemedicine Activities in India.
Prof. S K Mishra, MS, FACS
Head, Dept. of Endocrine Surgery
Nodal Officer Telemedicine
SGPGIMS, Lucknow,India
Question 14 1/2: ITU-D Study Groups
Rapporteur’s Group Meeting, Tokyo, Japan, 22 June 2005
Telemedicine
The use of advanced telecommunications
technologies to exchange health information
and provide health care services across
geographic, time, social, and cultural
barriers
Application of Telemedicine in Surgery
• Telesurgery– Telepresence Surgery– Telerobotics– Telementoring / Teleproctoring
• Tele healthcare for surgical patients– Teleconsultation (including intra-operative) – Pre referral screening– Tele follow up– Remote treatment planning
• Distant surgical education – Teleconferencing of surgical conferences, CMEs and Workshops – Web casting – Surgical education portals – Interactive virtual class room
Technical Requirement
• Broadband communication media
• High resolution display devices
• High end video camera
• Video-conferencing equipment
• Highly skilled technologist
• Equipments e.g. Surgical Robotics
Tele-surgery
Surgery, procedure or technique performed on
an inanimate trainer, animate model, or patient
in which the surgeon is not at the immediate
site of the model or patient being operated on.
Visualization and manipulation of the tissues
and equipment is performed using ‘electronic
devices’
Society of AmericanGastrointestinal Endoscopic Surgeons. Guidelines for the surgical practiceof telemedicine. Surg Endosc 2000; 14: 975-979.
Concerns about Telesurgery
• Cost of installing and maintaining a robotic system
• Safety of the procedure • Medico-legal • Licensing and regulation • Complications in Surgery
– Telesurgeon’s mistake– Technical failure
Source: Eadie LH, Seifalian AM, Davidson BR. Telemedicine in Surgery. Br. J. Surg 2003;90:647-658.
Benefits of Telesurgery
• Cost Effective• Expertise from National and International Specialists • Enhance and Extend the skill and range • Three dimensional fashion • Camera position can be controlled automatically
through voice command • Minimized surgical error & enhanced performance of
surgeon• Reducing Fatigue • Precise movements through robotic assistance
Source: Eadie LH, Seifalian AM, Davidson BR. Telemedicine in Surgery. Br. J. Surg 2003;90:647-658.
Benefits of Telesurgery
The robot can perform very precise surgery
The robot can insert screws into thevertebrae
Surgeon can practice using virtual reality technique
Robotic Surgery
• Robot assisted cardiac surgery
– All India Institute of Medical Sciences, New
Delhi
– Escort Heart Institute, New Delhi
– CARE Hospital, Hyderabad
• No reported case of tele-robotic surgery
Tele-proctoring
• Mentoring and evaluation of surgical trainees
from distance with the involvement of
broadband connectivity, power cams, and
sophisticated videoconferencing equipment
Source: Eadie LH, Seifalian AM, Davidson BR. Telemedicine in Surgery. Br. J. Surg 2003;90:647-658.
Tele-proctering:Amrita Institute of Medical Sciences (AIMS), Kochi (January 2003)
• AIMS set up temporary field telemedicine unit to provide public health and emergency care for the pilgrims of Sabarimala shrine
• Connectivity through satellite provided by Indian Space Research Organisation
• A patient with air trapped inside his chest cavity and one of his lung had completely collapsed came with life threatening condition
• Cardiovascular Thoracic surgeon from AIMS guided a cardiologist at field hospital to perform thoracic intervention using telemedicine technology
Stabilized patient after thoracic drainage performed through Telemedicine Technology
Source: http://arl.amrita.edu/telemedicine.html
Tele-mentoring
Real-time interactive teaching of
techniques by an expert surgeon to a
student not at the same site
Tele-mentoring Trial by SGPGIMS
• Between SGPGIMS, Lucknow and AIMS,
Kochi (April’ 2004)
• Primary Hyperparathyroidism
• Broadband telecommunication (ISRO)
•18 yr old boy , presented first in May 2002 at AIMS, Kochi
•Diagnosed as a case of primary hyperparathyroidism
•Operated in May 2002 – Failure (Tumor could not be located)
•Reoperated in July 2002 – Failure (Tumor could not be removed)
•Patient went home , reported after 2 years of Ayurvedictreatment
Case Study
• March 2004 :
Patient readmitted with advanced primary
Hyperparathyroidism with continuous body pains –
crippled, Bedridden with contractures , deformities
& bed sores
Case Study Contd.
Case discussed with SGPGIMS in one of the monthlytelemedicine session
Suggestions from SGPGIMS:a) Tumor has to be located and removedb) Offered assistance during surgery remotelyc) Detail road map of re-operation worked out d) Telementoring schedule fixed
Tele-consultation and Treatment Planning
1) Telemedicine centers at AIMS & SGPGIMS are connected with satellite link for regular telesessions
2) Video camera with cable link was installed in the Operation Theatre at AIMS
3) ISRO Hub was requested to provide 2 Mbps bandwidth during trial and on the day of telementoring
4) Trial teleconference of a live operation in real time from OTwas carried out a day earlier
Materials & Methods
Outcome
• The steps of operation was closely watched by the
Mentor
• At a key step the mentor guided the surgeon
• The surgeon followed the advice and located the
tumour which was verified by intra-operative
investigations
• 512 Kbps bandwidth was available
• Telementoring with exchange of good video &audio signals with satellite link is feasible in Indian settingbut more bandwidth needed
• Successful outcome in our case was largely due to the telemedicine technology.
• Difficult cases can now be operated without referralto higher centers with telementoring
Conclusions 1
Conclusion 2• Benefit for surgeon: self confidence boosted and
patient’s confidence regained
• Benefit to patient and Family: Logistics of transport to another hospital avoided, Direct financial and social benefit
• Benefit to hospital: Reputation regained, More complicated patient referred
• Benefit to health care delivery agency / Govt: Quality healthcare through technology intervention thereby people trust on system
• Cost factor & some legal concerns need to be addressed.
Tele-consultation in Surgery
• Evaluation of surgical patient(s), and/or
patient data
• No physical interaction with the patient
• Interaction through telecommunications
interface
Benefits of Tele-consultation in Surgery
• Initial urgent evaluation of patients, triage decisions, and
pretransfer arrangements for patients in an
urgent/emergency situation
• Intra-operative consultations
• Supervision and consultation for primary care
encounters in sites where an equivalently qualified
physician/surgeon is not available
• Routine consultations and second opinions based on
history, physical findings, and available test data
Tele-consultation in Surgery from SGPGIMS
(No. of Cases in each discipline)
44
26
25
3Endosurgery
Urology
Neurosurgery
Gastrosurgery
Tele-follow-up in Endocrine Surgery(March 2004 – April2005)
• Total number of patients : 34
• Males: Females : 1:2
• Age group : 14 to 67yrs
• Total no of visits/patient : 1 to 4 visits
65
35
13
9
0
10
20
30
40
50
60
70
Endo. Surgery Neurosurgery Gastro surgery Urology
No of Session
Specialty wise Telemedicine Sessions
(between SGPGIMS and Medical Colleges of Orissa)Sept’01 to April ’05
(Tele-consultation, Tele-follow-up, Tele-education)
Tele conferencing in Surgery
• Discussion and interaction between surgeons
in a virtual class room environment
• Live surgery demonstration
Source: Society of AmericanGastrointestinal Endoscopic Surgeons. Guidelines for the surgical practiceof telemedicine. Surg Endosc 2000; 14: 975-979.
Different kinds of teleconferencing modalities
• Interactive two way
• One way broadcast
• Web casting
1st Telesurgical Conference (1999)
• Live Surgery –
Cochin
• High Bandwidth (384
kbps) ISDN
• Interactive Live
Session
2nd Telesurgical Conference (2001)
• Entire Proceedings - SCB
Medical College, Cuttack
• Case Discussion - seven and
half hours
• Guest Lectures - six hours
• Endocrine Imaging – four
hours
• Live Surgery - fifteen hours
• 384kbps bandwidth ISDN
3rd Telesurgical Conference (2003)
• Entire Proceedings - SCB
Medical College, Cuttack
• Surgical Procedure -
Bangalore and Chennai
• Interactive Question Answer
Sessions
• 384kbps bandwidth VSAT
1st SGPGI, Breast Course – March 2005, SGPGIMS
• Entire Proceedings -
SCB Medical College,
Cuttack, Orissa,
AIMS,Kochi (Multipoint
connectivity)
• Interactive Question
Answer Sessions
• 3 ISDN Lines – 128
kbps
Tele-surgical Sessions in Virtual Classroom Environment
• Distance – 2500 km• Starting Date – March’ 04 – April’05• Total no of sessions In Endocrine Surgery & Surgical
Gastroenterology - 11
First World Summit on Kidney Surgery (February-2003) – AIMS, Kochi
• Urologists in many states in South India • Interactive participation • Live surgery workshop transmitted from
Cleveland, USA to over 12 countries worldwide
• Enabled Radiologists from AIMS to participate in the judge panel for radiology thesis presentations at SRMC, Chennai
Source:http://www.aimshospital.org/telemed.html
SN -MobileKarnataka• Chamarajanagar• Saragur
Karnataka• Chamarajanagar• Saragur
Orrisa• Cuttak• Burla• Berhampur
Orrisa• Cuttak• Burla• Berhampur
Andhra Pradesh• Aragonda• SHAR, Sriharikota
Andhra Pradesh• Aragonda• SHAR, Sriharikota
J& K• Srinagar-1• Srinagar-2• Jammu• Katua• Leh
J& K• Srinagar-1• Srinagar-2• Jammu• Katua• Leh
Lakshadweep• Kavaratti• Minicoy• Androttii• Ameni• Agatti
Lakshadweep• Kavaratti• Minicoy• Androttii• Ameni• Agatti
Kerala• Pampa• Pattanamthitta
Kerala• Pampa• Pattanamthitta
Andaman & Nicober• Port Blair• Car Nicobar
Andaman & Nicober• Port Blair• Car Nicobar
36 Nodes • 11 Super Specialty Hospitals• 25 Dist/ Rural Hosapitals
36 Nodes • 11 Super Specialty Hospitals• 25 Dist/ Rural Hosapitals
North East• Udaipur• Gangtok• Guwahati
North East• Udaipur• Gangtok• Guwahati
AMBULANCE
AIIMS,New Delhi
Apollo, New Delhi
NH, Bangaloare
SN, Bangalore
AIMS, Kochi MC,
Trivandrum
Apollo, Chennai
SRMC, Chennai
SGPGMI, Lucknow AHF,
Kolkota
SN, Chennai
ISRO’s TELEMEDICINE NETWORK - ESTABLISHED SO FAR (October 30, 2003)
> 12,000 patients treated
ShanlkaraNetralaya -
Mobile
Karnataka• Chamarajanagar• Saragur•Maddur.•Sagar.•Chitradurga•Karwar•Bagalkot.•Mandya.•Tumkur.•Sirsi
Karnataka• Chamarajanagar• Saragur•Maddur.•Sagar.•Chitradurga•Karwar•Bagalkot.•Mandya.•Tumkur.•Sirsi
Orrisa• Cuttak• Burla• Berhampur
Orrisa• Cuttak• Burla• Berhampur
Andhra Pradesh• Aragonda• SHAR, Sriharikota
Andhra Pradesh• Aragonda• SHAR, Sriharikota
J& K• Srinagar-GMC• Srinagar- SKIMS• Jammu• Katua• Leh• Kargil• Kupwara• Doda• Poonch
J& K• Srinagar-GMC• Srinagar- SKIMS• Jammu• Katua• Leh• Kargil• Kupwara• Doda• Poonch
Lakshadweep• Kavaratti• Minicoy• Androttii• Ameni• Agatti
Lakshadweep• Kavaratti• Minicoy• Androttii• Ameni• Agatti
Kerala• Pampa• Pattanamthitta• Kannur
Kerala• Pampa• Pattanamthitta• Kannur
Andaman & Nicober• Port Blair• Car Nicobar
Andaman & Nicober• Port Blair• Car Nicobar
113 Hospitals.--- 87 Dist/ Rural Hospitals,-- 26 Super Specialty Hospitals113 Hospitals.--- 87 Dist/ Rural Hospitals,-- 26 Super Specialty Hospitals
North East• Udaipur(TP)•Guwahati(AS)• Imphal-1(MP)•Jorhat.(AS)•Shillong(MG)•Mokokchung(NL)•Naharlangun(ap)• Gangtok(SK)
North East• Udaipur(TP)•Guwahati(AS)• Imphal-1(MP)•Jorhat.(AS)•Shillong(MG)•Mokokchung(NL)•Naharlangun(ap)• Gangtok(SK)
AMBULANCE
AIIMS,New Delhi
Apollo, New Delhi
NH, Bangaloare SN,
BangaloreAIMS, Kochi
MC, Trivandrum
Apollo, Chennai
SRMC, Chennai
SGPGMI, Lucknow
SN, Chennai
SSKM Kolkata
ISRO’s TELEMEDICINE NETWORK - ESTABLISHED SO FAR
> 20,000 patients treated
R& R,New Delhi
ARMY• Srinagar• Siachin• Leh• Kargiil• Udhampur
ARMY• Srinagar• Siachin• Leh• Kargiil• Udhampur
RCC, Trivandrum
Chhattisgarh• Jagadalpur• Raipur•Marwahi
Chhattisgarh• Jagadalpur• Raipur•Marwahi
West Bengal• Krishnanagar•Malda
West Bengal• Krishnanagar•Malda
AHF, Kolkata
Arvind Eye Hospital
TMC Mumbai
Kerala Oancer net• Cancer center KannurKerala Oancer net• Cancer center Kannur
• B.Barua CC Guwahati.
•Walwaker CC,Chiplun
• B.Barua CC Guwahati.
•Walwaker CC,Chiplun
AMBULANCE
Arvind Eye Hospitalmobile
ISRO Projects under Development
• Development of revenue model of Telemedicine in
public-private partnership model (Philips, Apollo &
ISRO)
• All India Medical College Network in partnership with
IT, Health Ministry & Medical Universities
• Deployment of Village Resource Center
Department of Information Technology (DIT), Govt. of India
• Developed document on Telemedicine
standardization
• Developed document on IT infrastructure for
health
• Funding of R&D projects for health IT
• Setup 45 Telemedicine nodes
DITInitiatives
• Development of telemedicine software & application (C-DAC,AIIMS,SGPGIMS & PGIMER)
• Development of Telemedicine module for Tropical Medicine in West Bengal - Webel (Kolkata), IIT,Kharagpur and School of Tropical Medicine, Kolkata
• Development of Tele-oncology Network - Kerala and Tamilnadu States
• Development of state wide Telemedicine network based on terrestrial communication in the state of Himachal Pradesh
Telemedicine at SGPGIMS,Lucknow
• Telemedicine application project
• Consultancy, project planning and implementation of Telemedicine network in 3 states of Orissa, Uttaranchal, Uttar Pradesh and states of north east of India
• Tele-Consultation & Distant Education in Medicine
• Tele-mentoring
• Research and Product development in Tele- Health in collaboration with Industry
• Human Resource development in Tele-Health
Telemedicine at SGPGIMS,Lucknow Contd..
• Organisational activities in Telemedicine
• Telemedicine awareness activities for
healthcare providers and other stake holders
• National & International collaboration in
technical knowledge exchange & HRD
Human Resource Development & Capacity Building
Initiatives
• Telemedicine• Hospital information system• Medical Image Management and Multimedia• Development of multimedia medical
education Content and Distant Education• Artificial Intelligence• Bio-informatics• Virtual reality in Medicine• Medical robotics
HUBHUBHUB
MEERUT
AGRA
ALIGARH
KANPUR
KGMU,LUCKNOW
ALLAHABAD
VARANASISGPGIMSSGPGIMSLUCKNOWLUCKNOW
UP TELERADIOTHERAPY NETWORK:Department of Science & TechnologyUP TELERADIOTHERAPY NETWORK:Department of Science & Technology
Radiotherapy Network at SGPGIMS
Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh
• To provide modern health facilities at affordable prices in remote areas PGIMER, linked with– Mata Kaushalya Hospital at Patiala– Sub-divisional government hospitals at
Dasuya and Ajnala in Hoshiarpur and Amritsar in Punjab state
Source:http://www.hindu.com/2005/04/14/stories/2005041405310500.htm
The Amrita Institute of Medical Sciences (AIMS), Kochi
• To extend specialty medical care to patients at remote locations• To provide follow-up of post-surgical patients, avoiding needless
travel on their part • To strengthen the skills and confidence of doctors at remote
primary centers and help them build a better relationship with their patients.
• To provide Continuing Medical Education to the Doctors at the peripheral centers and other general hospitals with the latest advancement in the field of Medicine
• To promote Interactive Medical Education between thespeciality medical centers
• To develop low-cost telemedicine software, medical equipments like Patient Monitors for remote management of the patient at the Specialty Centre.
Source:http://www.aimshospital.org/telemed.html
AIMS, KochiEstablished Connectivity
• 36 Telemedicine Centers all over India • Emergency Medical Center at Pampa • Other Tertiary Level Hospitals
– Sree Ramachandra Medical College, Chennai, – Sankara Netralaya, Chennai, – Sanjay Gandhi Post Graduate Institute of Medical Sciences,
Lucknow, – Guwahati Medical College, Assam, – Sher-E-Kashmir Institute of Medical Sciences, J & K, – AIIMS, New Delhi, – Trivandram Medical College, Narayana Hrudayalaya,
Bangalore
Source:http://www.aimshospital.org/telemed.html
Apollo Telemedicine Network FoundationInitiatives
• Corporate Group of Hospitals having branches in India and Abroad
• Networked all its hospitals and use in-house software• Telemedicine consultancy and software providers• Active participants in the Standardization and ITIH activity• Installed a number of peripheral telemedicine nodes
through franchise under Apollo Health Street Company • One of the major player in telemedicine in private sector
Apollo Telemedicine Network Foundation
• Set up over 75 Telemedicine Centres across different
locations in the country and abroad
• Set up a Rural Telemedicine Centre in the village of
Aragonda in the state of Andhra Pradesh which
serves 24 villages covering 48,000 people in the
vicinity and provides access to super-specialists at
the Apollo hospitals in Chennai
Source:http://www.whoindia.org/EIP/GATS/13-Annex2.pdf
http://medind.nic.in/maa/t05/i1/maat05i1p51.pdf
Asia Heart FoundationInitiative
• One of the major private player in telemedicine service provider
• Network number of hospitals in India and Abroad• Most of the service related to cardiac care• Southern Grid operates through Narayana
Hrudayalaya, Bangalore • Eastern Grid operates through R N Tagore
Hospital, Kolkota
Telemedicine by Narayana Hrudayalaya, Bangalore
• Tele-cardiology network in the state of Karnataka, West
Bengal and North East State
• Tele-monitoring of distantly located coronary care unit
• 39 telemedicine centers
• More than 16,4000 Tele-cardiology consultation in India,
Malaysia, Mauritius and Pakistan completed
Shankara NethralayaMobile Tele-ophthalmology Unit
(Real time and Store and Forward)
• Telemedicine Software and Hardware
• 29 inch flat Television
• Ophthalmology Equipments
• Video Slit lamp
• Digital Fundus Camera
• Video Indirect Ophthalmoloscope
• Tonometry
• Connectivity
• VSAT - 384 Kbps
• Laptop with Project and Screen
• Portable wireless amplifier with cordless mike
• Digital Camera
• VHS recorder
Shankara NethralayaTele-ophthalmology ( Statistics upto – March 2005)
7,393Door to Door Enumeration
14,791Awareness meeting attended
250Bangalore Teleconsultation
819Spectacles given 5,852No. of Teleconsultations15,043No. of patients examined
315No. of Camps
TotalParticulars
Total No. of patients benefited so far due to Teleophthalmology : 21,145
Aravind Eyecare Hospital(Tele-ophthalmology)
• Tertiary care on wheels• Centers at Madurai, Theni, Tirunelveli &
Coimbatore districts of South India
Source:http://www.aravind.org/telemedicine/atnnet.htm#
Escort Heart Institute Initiatives
• Escort Heart Institute &Research Center, New Delhi
• Networked all its hospitals, mostly in Northern India
• One of the major player in private sector
• Only delivers tele-cardiology service
Tata Memorial Hospital
• Started Tele-pathology service linking with Rural Cancer Hospital at Barshi in 2002
• Tele-oncology service for
– Dr B Borooah Cancer Institute, Guwahati
– Dr Walawalkar Hospital at Dervan, Chiplun
• Networking of six hospitals in the North-East and Regional Cancer Centres to enable patients to access comprehensive cancer care
Source:www.tatamemorialcentre.com
Indian institute of Technology, KanpurProject1 – Sehat Sathi
Development of Portable Mobile Rural Healthcare Module
• Software package (Sehat Sathi)– Medical data acquisition – ECG, Eye images, heart &
lung sounds etc)– Interaction between doctor and patient– Rural patient health database management– Content on health & disease:towards health promotion
(www.bimarijankari.org, www.sehatnama.org)
• Source:www.medialabasia.org.in
www.iitk.ac.in
Indian institute of Technology, KharagpurProject2 – Sanyog
• Augmentative Communication System for the speech impaired & people affected with cerebral palsy
• Sanyog System– Natural Language Sentence Generator– Icon Interpretation& Disambiguation– Text to speech system– A predictive virtual key board – Facility to store & retrieve frequently used
messages– Varied access switches
• Languages support – Bengali, Hindi & English• Tested in the field of West Bengal
Source:www.medialabasia.org.in
www.iitkgp.ac.in
Indian institute of Technology, KharagpurProject3 – Shruti
• An Embedded Indian Language Text to Speech System
• Accepts text inputs in two Indian languages – Hindi & Bengali
• Text enter in ITRANS using Roman Characters• Provides a speech based communication interface
for speech impairments& forms an integral part of a talking web browser for visually challenged
Source:www.medialabasia.org.in
www.iitkgp.ac.in
All India Institute of Medical Sciences, New Delhi Project 4 – Ca:Sh
• A replicable model for IT based health system at grass root level
• Developed handheld device for health data collection• Computerised data is maintained at PHCs & CHCs• Data at PHCs & CHCs is digitally updated from the
data on handheld devices• Enables automated generation of work plan on
handhelds• Management of childhood diseases and other
applications
Indian institute of Technology, KanpurProject5 – Infothela
• Designed to accommodate diagnostic equipments like– blood pressure testing machine– blood sugar testing machine– other primary health diagnostic and testing equipments.
Source:www.medialabasia.org.in
www.iitk.ac.in
Indian institute of Technology, DelhiProject 6– Zero Configuration wireless mesh
network
• All wireless network – a mesh of access points
(802.11b)
• Deployment requires no manual configuration
• Readily deployed while offering connectivity and
mobility to any network-ready mobile device
• Used for disaster mitigation & management, sensor
networks & applications requires automatic
configurability
Byrraju FoundationProject Ashwini
• 32 Ashwini centers – services offered by these Ashwini centers will be accessed by these and 84 neighboring villages of Andhra Pradesh, South India
• Covering a total population of over 500,000
• Online consultation with specialists to complement the Primary Healthcare efforts
• Broad spectrum coverage – Gynecology, Diabetes, Hypertension, Eyecare, Pediatrics, Epilepsy, Health Education & Promotion
• Continuous Medical Education
International Conference on Telemedicine by
Indian Space Research Organisation (ISRO)