EHEALTH: INDIA

Implementing telemedicine technology: lessons from Indi

SANJAY P SOOD, M.TECH,
HEAD OF SCHOOL, C-DAC SCHOOL OF ADVANCED COMPUTING, MAURITIUS

Abstract
Information and communications technologies have universally helped to bridge the digital divide. As an application of ICT, telemedicine is an efficient pathway for enabling health care delivery. Developing countries, too, have started reaping the benefits of this evolutionary technology, but realisation of such dreams has not been swift. The implementation of a pilot scheme in telemedicine in India has been confounded with challenges right from the very start. One of the prime lessons learnt to be learnt from the implementation of a pilot project in a developing country is to keep the objectives of the project in small modules and to keep the deliverables within sight. An account of some of the challenges faced while developing telemedicine technology in India serves as a useful example for upcoming telemedicine programmes in Third World countries. Voir page 40 le rsum en franais. En la pgina 41 figura un resumen en espaol.

evelopmental efforts in any country are aimed at launching newer schemes and projects relevant to the population of that country. A significant part of these efforts are directed towards addressing the inequities already existing within the country itself. Often, geographical and socioeconomic factors are at the heart of the problem. These inequities are profound in areas like education and health care delivery. From a broader perspective technologies like telemedicine, telehealth and ehealth are some of the applications of Information and Communications Technologies (ICTs) which not only act as pathways towards solving these inequities, but they also help in bridging of the digital divide, too. The rationale for developing a telemedicine system is to serve populations that have limited access to high-quality, diagnostic, therapeutic or educational medical services hence compensating for the shortage of health care professionals and providing healthcare services to the population in rural and remote areas1. The use of telecommunications for health care goes back to early 1900s2. Yet these applications have taken longer than expected to trickle down to the developing world. Challenge is a term synonymous with developing countries. The implementation of plans, designs or research, will often be confronted with unforeseen challenges arising from projects using state of the art technologies and so spill over in time and also at times stray from their objectives, as well as failing to meet other various deadlines or benchmarks. The affects of these challenges are even more likely when

development pertains to technologies like telemedicine which are the state of the art and multi-disciplinary. Whilst developing a pilot scheme for an integrated telemedicine technology in India a developing country (Indias Human Development Index rank has fallen from 115 in 2001 to 127 in 2003), the experience has truly been a learning curve, primarily because of the challenges faced. Being a pilot project, virtually the entire exercise of developing the telemedicine technology was a challenge each step brought with it a different kind of a challenge and many of the challenges that came up were surprises. The very vision itself to plan an acceptable technology that was in a way non-existent in the clinical set-ups posed the biggest challenge. Some of the major challenges faced during the development of this integrated telemedicine system have been described below. Benchmarks The initiation of the project was challenging primarily for the reason that history and telemedicine in Indian context did not converge. There had been no Indian precedent relevant to the project. There was no current source to consult for advice on telemedicine in India. Internationally, too, in 1998, the pioneers were still discussing the rapidly evolving definition of telemedicine. In such a challenging situation there was indeed a silver lining and that was encouragement from the funding agency the Ministry of Communications and Information Technology (formerly the Ministry of Information

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Technology) and the support of some forward looking clinicians at the government-run tertiary level hospitals. Technology In such pioneering situations, there were issues like the method of data transfer (real time or store and forward), the applications of telemedicine for practicing specialities (teleradiology or telecardiology or telepathology or Telepsychiatry or tele-education), and the selection of platform to be resolved. System requirement specifications took time to be finalised. Eventually the development had to move further to the next step with some of the issues yet in abeyance. Communication services The selection of Telemedicine programmes backbone communications and the networking technologies were an inherent challenge, except for Integrated Services Digital Network (ISDN) and there was not much to choose from. With sustainability as the key word, communication services like satellite communications were not the appropriate choice for obvious reasons. Hence the only option was ISDN the then state of the art technology in Indian communications sector. This unanimous and forced selection as the backbone of the telemedicine programme brought with it a range of challenges which were evolving with the technology. Those included inexperience of the telecommunications service provider, issues related to the quality of qervice, ISDN etc. User friendliness Developing an application based on communications technologies for a diversified group of users ranging from clinicians (in minority) with considerable knowledge about handling digital versions of clinical data and on the other side the majority of clinicians who took time to establish control over the technology. A careful balance had to be struck between user-friendliness and the advanced features. This was one of the bigger functional challenges all through the projects life cycle. The challenge appeared bigger and tougher specially when the application of this technology was to be made for a lesser IT savvy group of clinicians (at primary level) . The approach was to work out a technology that was acceptable to the clinicians in tune with the perceived usefulness and the perceived ease of use.3 Equipment The finalisation, selection, procurement and installation of the equipment had been a rather difficult exercise primarily for the reason that the range of PC based medical equipment required for the technology was yet not available in India References
Fostering the application of telecommunication in health care. Identifying and documenting success factors for implementing telemedicine, Question 14/2, Study Group 2, Telecommunication Development Bureau, ITU (1999). 2 California Telemedicine and eHealth Centre http://www.cttconline.org/telemedicine_history.html (accessed on 26th September, 2004) 3 Davis, F.D. Perceived Usefulness, Perceived Ease of Use, and User Acceptance
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and hence had to be imported. There was virtually no support for the equipment locally and problems in such cases are of many different kinds, for example, when a component from a medical film scanner broke down during transportation from North America, it took over two days to identify the fault. The fault was detected, but only after support from the North American manufacturer through a series of video conferencing sessions during the night (to suit the American manufacturer). Training of clinicians on telemedicine technology Training of clinicians on the telemedicine technology had been challenging, too. The efforts were: to keep the clinicians motivated enough to voluntarily appear for the next training session; make them understand about the very concept of digitized clinical information. Training had to be reinforced with local real life instances. Course of planning There were many instances where the course of planning had to be revised, primarily because of the lack of standards existing in the country at the time. The non-availability of journals, back issues and limited experience were also the reasons for such revisions. Efforts and contributions from pioneers in the West also took time to be accessible and available. The rate of reviews had to be stepped up. Conclusions Despite these challenges, the technology could eventually be implemented at three tertiary level hospitals in India3. The component of tele-education has been the most popular amongst the clinicians right from the beginning, other applications of telemedicine are gaining momentum. Owing to larger scope of applications in developing countries, telemedicine may have more impact there4. Telemedicine being a multi-disciplinary domain and needs fields like medicine, ethics, science, computers and ecommerce to converge. Convergence at this scale in a developing country may not be an overnight change, as it needs synergetic efforts from all perspectives. The development and implementation of telemedicine technology are pre-requisites for introducing telemedicine into a developing country, but some other postimplementation challenges like grooming a forward looking charismatic and energetic IT-aware clinicians, behavioural change, infrastructural preparedness, resolving issues pertaining to sustainability, training, legal and ethical aspects, standardisation and interoperability have to be overcome to experience the timely fusion of telemedicine into respective traditional health care delivery systems.

of Information technology, MIS Quarterly (12:3), 1989, pp 319 - 339. Sanjay P Sood & R.S. Khandpur, Indian National Telemedicine Project an . Overview, First Telemedicine and Telecare International Trade Fair, April 10-12, 2002 at Luxembourg. 5 Steven M Edworthy, Telemedicine in developing countries, BMJ 2001; 323, p524-525.
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