Scenario I: 13 January 2003, 4 am, All India Institute of Medical Sciences (AIIMS), Delhi. An unearthly hour but this hospital is bursting with people queuing up to get a token for medical consultation later in the day. By the time doctors arrive, minor scuffles and fights have already taken place. All this pain just for a few minutes with India's premier doctors.

Scenario II: 13 January 2003, Amrita Emergency Care Unit at Pampa. On the way to Sabarimala shrine, a cardiac patient becomes critical and arrives here. The emergency unit established a link with Amrita Institute of Medical Sciences (AIMS), Kochi and the cardiovascular thoracic surgeon at Kochi assists the surgeon at Pampa to perform a life-saving procedure.

In both the scenarios expert medical opinion is necessary for saving lives and alleviating pain. However, in the second scenario, the integration of IT and communication technology with the health services saved time, money, the harassment of traveling to a super-specialty hospital, and perhaps even a life. This is the power of tele-medicine.

Urban vs Rural
Though India takes pride in its diversity and size, the very fact makes it difficult to provide sufficient-quality health services to every person. The Economic Survey 2003–04 shows over Rs 36,800 crore being spent on healthcare services, which is 4.5 percent of the total government expenditure.

The current investment in public health is 0.9 percent of the GDP. The National Health Policy 2002 aims to increase this to two percent. However, 75 percent of the qualified doctors practice in urban areas, 23 percent in semi-urban (towns). But the rural areas, where 72 percent of our poupulation resides, have only two percent of the doctors and 0.10 hospital beds per 1000 people. It is estimated that only one hospital bed is available for 1,333 Indians, and one doctor per 15,500 people.

Doctors agree that it is not feasible for them to stay in one remote area and wait for patients all day. Instead they can utilize their skills better, by serving more, while being connected to various places and giving consultations as and when required. Thus, the concept of tele-medicine was born.

ISRO Comes to the Rescue
Telemedicine in India took off when ISRO lent a few transponders on INSAT and provide VSAT connectivity to various specialty hospitals like AIIMS, Army Research and Referral, Apollo, Sankara Nethralaya, and Amrita Institute of Medical Sciences with hospitals in remote areas like Leh, tribal areas of Chattisgarh, upper reaches of Uttranchal, and Northeastern states. Today there are 90 tele-medicine nodes installed by ISRO, including doctor and patient centers.

The tele-ophthalmology facility at Sankara Nethralaya minimizes delay in the diagnosis of ocular diseases, and offers diagnostic facilities to remote areas. They are also use this facility to train ophthalmologists serving in the rural areas.

A tele-medicine session in progress at Sankara Nethralaya, Chennai

Private hospitals like Ranbaxy-promoted Fortis have networked their hospitals over ISDN lines. Fortis has an online monitoring facility at its Amritsar hospital. Records of any patient at it can be accessed online from any of the Fortis hospital. The group is also working to connect nursing homes with its Noida center, to provide consultation in orthopedic cases.

Hewlett-Packard's i-community project has three mobile mobile vans linked to PES Medical College and Specialty Hospital in Kuppam and provides eye testing and online consultation in the villages. Apollo has tele-medicine centers in Lahore, Colombo, Khazaktisthan; and plans to cover Kathmandu and Yemen by year-end.

Remote Healthcare? Well, Not Yet
In India telemedicine has been limited to education and second consultations. Further, these services have been limited mostly to communications between hospitals. The government is also planning to connect the primary health centers to the district hospitals, which in turn are going to be connected to specialty hospitals and medical colleges. In the true sense, rural areas have not yet been covered and, hence, the impact of tele-medicine is difficult to assess.

The term remote, as used in tele-medicine parlance, means an area not easily accessible or one which has been cut off due to some calamity. For example, telemedicine was very helpful in treating people during the Gujarat earthquake and Orissa cyclone. In places where taking a critically ill patient to a specialty hospital would take time, such as from Leh, Gangtok, Port Blair, Kavaratti, or Kohima, such facilities have saved many lives. During the Kumbh Mela in Haridwar, three lives where saved when paramedics contacted SGPI, Lucknow and took treatment instructions over the tele-medicine network.

However, there are very few instances of such surgeries being assisted remotely, as fail-proof connectivity is a prerequisite to even conceptualizing such the procedure. Though, even with the current level of communications, pre-operative and post-operative observation and consultations have taken off.

Broken Links
The primary idea behind tele-medicine was to reduce the pressure on specialty hospitals while ensuring anywhere, anytime, good healthcare facility. At the moment, this does not seem to be happening. Though steps are being taken to create an e-data base of the patient, which the doctors may access from anywhere in India, the initiatives are falling short. In fact, at many nodes, the usage is very low and has failed to attract attention.

Tele-consultation in progress. The patient is seeking a specialist's opinion through a visiting mobile van

Though the cost of access devices and bandwidth charges have come down, the service quality has not improved. Raising funds has been the main reason for this facility not being extended to rural areas. The private hospitals are asking the government to establish the network so they may provide specialist consultations.

As for the existing nodes, the rate of adoption, comfort level, and ease of use of technology have proved to be the main barriers. Doctors are looked upon as gods in our country, especially in rural areas. Sometimes, some of them don't encourage patients seeking a second opinion, and it is unlikely that without their encouragement the patient would go for a tele-consultation with another specialist.

Tele-medicine can succeed but only if the mindset of patients and doctors changes and a level of confidence is established in the new technique of healing and alieviating pain. A patient's awareness and demand for specialist opinion through tele-medicine is a must for this initiative to survive.

Anurag Prasad