community medicine #telemedicine #public health

1. TELEMEDICINE : In the
context of Public
health
-DR SNEHA SIMON
POST GRADUATE (MD SPM)
DE DEPARTMENT OF COMMUNITY MEDICNE

2. CONTENTS
1. TELEMEDICINE VS TELEHEALTH
2. USES OF TELEMEDICINE FOR PATIENTS AND DOCTORS
3. TELEMEDICINE : GLOBAL SCENARIO
4. TELEMEDICINE: INDIAN SCENARIO
5. TELEMEDICINE UPDATED REGULATION BY MOHFW (2020)
6. KEY INITIATIVES UNDER GOVT OF INDIA FOR TELEMEDICINE
7. IMPACT OF TELEMEDICINE IN INDIAN HEALTH CARE
8. CHALLENGES FACED
9. CONCLUSION
10. REFERENCES

3. TELEMEDICINE
EXCHANGE OF VALID INFORMATION REGARDING DIAGNOSIS,
TREATMENT AND PREVENTION OF DISEASES AND INJURIES AND ALSO
RESEARCH AND EVALUATION USING TECHNOLOGIES TO IMPROVE
HEALTH OF INDIVIDUALS AND THEIR COMMUNITIES AND ALSO FOR
THE CONTINUATION OF EDUCATION FOR HEALTH CARE PROVIDERS.

4. TELEHEALTH
INCLUDES;
1. ONLINE CONSULTATION
2. HEALTH INFO SERVICES
3. SELF CARE APPS

5. TELEMEDICINE VS TELEHEALTH
TELEMEDICINE IS USED TO DENOTE CLINICAL SERVICES DELIVERED BY
RMP THROUGH ONLINE.
VS
TELEHEALTH IS A BROADER TERM= USE OF TECHNOLOGY FOR HEALTH
AND HEALTH RELATED SERVICES. EG: HEALTH RELATED APPS

6. USES OF TELEMEDICINE ( PATIENTS)
• NO NEED OF LONG DISTANCE TRAVELLING
• TIMELY AND FASTER ACCESS
• DECREASED COST
• USEFUL FOR ROUTINE CHECKS UP AND CONTINOUS MONITORING
• USEFUL DURING ANY DISASTER AND PANDEMICS

7. USE OF TELEMEDICINE FOR DOCTORS
• DURING INFECTIOUS PANDEMICS
• DURING DISASTERS
• CAN ACCESS PATIENTS FROM DIFFICULT TO REACH AREAS ALSO
• CAN HAVE ONLINE DISCUSSION WITH A SPECIALIST ALSO REGARDING
CASES.
• BETTER DATA RECORDING AND MAINTENANCE THAN IN PERSON
CONSULTATION.

8. TELEMEDICINE DURING DISASTERS

9. TELEMEDICINE: A GLOBAL SCENARIO
• In the US, approximately 100,000 telemedicine consults are
performed each month.
• there are 80 million doctor/patient consultations each month in the
US.
• Evidence shows telemedicine has been used in essentially all
countries of the world, but is embedded in few.
• Telemedicine is still not integrated into existing health care systems
globally.

10. CHALLENGES FACED IN DEVELOPING
COUNTRIES
• limited resources
• unreliable power
• poor connectivity
• high cost for the poverty stricken

11. TELEMEDICINE IN INDIAN CONTEXT
• ISRO (Indian Space Research Organization) made a modest
beginning in telemedicine in India with a Telemedicine Pilot Project in
2001, linking Chennai's Apollo Hospital with the Apollo Rural Hospital
at Aragonda village in the Chittoor district of Andhra Pradesh.
• Initiatives taken by ISRO, Department of Information Technology
(DIT), Ministry of External Affairs, Ministry of Health and Family
Welfare and the state governments played a vital role in the
development of telemedicine services in India.

12. • the Government of Uttar Pradesh practices telemedicine during Maha
Kumbhamelas.
• The current major Indian private sector players in telemedicine
include Narayana Hrudayalaya, Apollo Telemedicine Enterprises, Asia
Heart Foundation, Escorts Heart Institute, Amrita Institute of Medical
Sciences and Aravind Eye Care.
• GOI has set up a National Telemedicine Portal for implementing a
green field project on e-health establishing a National Medical College
Network (NMCN) for interlinking the Medical Colleges across the
country with the purpose of e-Education and a National Rural
Telemedicine Network for e-Healthcare delivery.

13. • Telemedicine practices in India are also extended to the fields of
traditional medicine.

15. MOHFW GUIDELINES FOR TELEMEDICINE
REVISED MARCH 25 2020.

16. TELEMEDICINE : TOOLS USED

17. MODES OF COMMUNICATION IN
TELEMEDICINE

18. TYPES OF TELEMEDICINE : BASED ON
1. MODE OF COMMUNICATION: audio / video/ text
2. TIMING OF INFORMATION: real time video/audio & asynchronous
exchange of information.
3. PURPOSE OF CONSULTATION: first, follow up & emergency consult
4. INDIVIDUALS INVOLVED :
• Patient->RMP
• Caregiver->RMP
• RMP->RMP
• Health worker -> RMP

19. Patient -> RMP RMP-> RMP

20. Health worker -> RMP

21. ELEMENTS OF TELECONSULTATION
• CONTEXT
• IDENTITY OF PATIENT AND DOCTOR
• MODE OF COMMUNICATION
• CONSENT OF THE PATIENT
• TYPE OF CONSULTATION
• PT EVALUATION
• PT MANAGEMENT

22. 1. CONTEXT: RMP should decide whether telemedicine is appropriate
in a given situation.
2. IDENTITY OF PT AND RMP: both should reveal their identities
3. MODE OF COMMUNICATION: whichever is relevant for the given
condition of the patient
4. CONSENT OF PATIENT: very important before any teleconsultation

23. 5. TYPE OF CONSULTATION:
1st CONSULT:
• Consultation for the first time (or)
• Last consult 6 months back (or)
• Consulted recently for a different condition.
FOLLOW UP CONSULT:
• Same RMP within 6months of previous consultation.
NOT A FOLLOW UP:
• Presenting with new c/f of the same health condition.
• RMP does not recall the context of previous treatment or advice.

24. 6. PATIENT EVALUATION:
• Gather relevant information ( history, examination, lab reports, past
records, etc)
• If information is inadequate ask for additional information from the
patient .
• Provide health education as appropriate at any time

25. • If physical examination is mandatory do not proceed without it
• Whenever necessary recommend;
Video consultation
Examination in person
Discussion with other specialists
• Maintain all patient records.

26. 7. PATIENT MANAGEMENT
• Provide health education as appropriate
• Provide counselling
• Prescribe medicines according to the categories
• Medicines which can be prescribed through telemedicine will be
revised time-time.

27. LIST OF MEDICINES USED IN TELEMEDICINE

30. MEDICAL ETHICS RELATED TO TELEMEDICINE
• Maintain patient confidentiality and privacy
• Misconduct : misusing pt’s images, prescribing restricted medicines
• Maintain records and documents
• Fee: appropriate
• Give the receipt of charge to patients
• Pt has the right to choose to discontinue the teleconsultation at any
time.

31. MANDATORY TELEMEDICINE COURSE OF RMP
• An online program will be developed and made available by the Board
of Governors in supersession of Medical Council of India.
• All registered medical practitioners intending to provide online
consultation need to complete the mandatory online course within 3
years of its notification.
• In the interim period, the principles mentioned in these guidelines
need to be followed.
• Thereafter, undergoing and qualifying such a course, as prescribed,
will be essential prior to practice of telemedicine.

32. TELEMEDICINE IN EMERGENCY SITUATION
• Avoid tele consultation during emergency situation.
• In some emergency, teleconsultation can be used to provide basic
first aid care.
• Eg: trauma: advise about right positioning of limbs , spine and neck.
• Facilitate referral

33. TECHNOLOGY PLATFORMS
• Apps related to health
• Doctors are mandatory
• Name, qualification, reg no, contact no should be listed
• Artificial intelligence alone based apps : not allowed
• AI should be an assistance for doctors
• Should have separate query and grievance portal for consumers.

35. TELEMEDICINE APPS FOR COVID
1. T COVID -19 : app by govt of telangana
2. HITAM : home isolation telemedicine and
monitoring app by telangana govt.

36. KEY INITIATIVES OF GOI FOR TELEMEDICINE
1. NATIONAL MEDICAL COLLEGE NETWORK
2. NATIONAL AND STATE TELEMEDICINE NETWORK
3. SATCOM BASED AT PILGRIM PLACES
4. JIPMER BIMSTEC
5. TELE EVIDENCE

37. NATIONAL MEDICAL COLLEGE NETWORK
• Project implemented under telemedicine
• To interlink all medical colleges of country with high speed optic fiber
backbone from national knowledge network
• Objectives: to create a standard and cohesive environment for
medical education.
• E classrooms started at 50 medical colleges : distance learning and
education.
• Live webstreaming of medical lectures.

39. NATIONAL AND STATE NETWORK
• To provide telemedicine services to remote areas by upgrading
existing health services.
• In medical colleges, district hospitals, sdh, phc and chc
• Hub and spoke model
• Hub: doctors (MBBS/ PG residents)
• Spoke: PHC
• 10 states have implemented state telemedicine network

41. SATCOM BASED
• Using space technology tools.
• Provides health awareness, screening for NCDs and speciality consultation
to devotees using these places
• Active sites:
 UP: kaashi
Mirzapur: vindhyavasini mandhu
JK: amaranth
Kerala: sabrimala
• Speciality consultation from any super speciality nodes ( AIIMS, JIPMER,
PGIMER, SGPGI )

43. JIPMER BIMSTEC
• BIMSTEC: bay of Bengal initiative for multi sectoral technical and
economic cooperation region.
• Launched: July 13th 2017

44. • Aim:
 to improve regional cooperation in the field of health care by
strengthening telemedicine based patient care services sand share
knowledge among BIMSTEC countries .

45. TELE EVIDENCE

46. NRC AND RRC’s
• NRC: national resource centre in SGPGI LUCKNOW
• RRC: regional resource centre ( seven centres )
• North : PGI CHANDIGARH
• Central: AIIMS DELHI
• South : JIPMER
• East: IMS, BHU, VARANASI
• West: KEM, Mumbai
• North east : NEIGKIHMS, shilong
• South II: Trivandrum

51. APPLICATIONS OF TELEMEDICINE
• Education
• Health care delivery
• Health care management
• Disaster management
• Screening of disease

52. 1. EDUCATIONAL
Tele-education: A flexible and interactive long distance learning
programme providing easier training and updates of the recent
advances for more accurate and effective treatment methods.
• Tele-Conferencing: Discussion and interaction between doctors during
workshop, conferences, seminar or continual medical education
programs in a virtual room environment.
• Tele-Procutoring: Mentoring and evaluation of surgical trainees from
distance with the involvement of sophisticated video-conferencing
equipment.

53. 2. HEALTHCARE DELIVERY
School-Based Health Centers: Helps manage chronic conditions like
bronchial asthma, diabetes and obesity. Telemedicine allows a school
nurse, remote access to specialist medical opinion.
• Correctional Facilities: Cater to the healthcare needs of the inmates
without the expense and dangers of inmate transportation or the
need for a specialist doctor to enter.
• Mobile Health Clinics: Provides quick access to a remote physician or
medical specialist.
• Shipping and Transportation: Helps avoid evacuations and
unscheduled diversions during a medical emergency.
• Industrial Health: Provides medical management and triage advice
on-site.

54. 3. HEALTHCARE MANAGEMENT
Tele-health care: Use of ICTs for preventive and promotive healthcare;
it is further divided into teleconsultation and tele-follow up.
• Tele-home health care: Monitor patients from a central station
(Remote patient monitoring) with the help of a Computer Telephone
Integrated (CTI) system for 24 hour vitals monitoring.
• Specialties like tele-ophthalmology, tele-psychiatry, tele-cardiology,
and tele-surgery.
• Diagnostic services like tele-radiology and tele-endoscopy.

55. 5. DISASTER MANAGEMENT : A mobile and portable telemedicine
system with satellite connectivity and customized telemedicine
software is ideal for a disaster stricken region where all other modes of
connectivity are disrupted.
Examples:
NASA tele-medicine services provided during 1985 Mexico City
earthquake and 1988 Soviet Armenia earthquake.
• Amrita hospital tele-medicine services provided during 2004 Tsunami
disaster.

56. 4. SCREENING OF DISEASES
Examples:
Diabetic screening project by MDRF: The Chunampet Rural Diabetes
Prevention Project.
• Ophthalmology screening by Aravind Hospitals at Andipatti village.

57. IMPACT OF TELEMEDICINE : PUBLIC HEALTH
• The technology involved in telemedicine allows providers and patients to
be almost anywhere, this is one of the key factors in providing quality
healthcare to the needy. With the advent of telemedicine, distance is no
longer a hurdle in providing healthcare to the remote areas.
• The initial challenge for the commencement of the programme posed by
the lack of a primary center for practicing telemedicine services in many
remote areas was resolved with the kickoff of mobile telemedicine units
with satellite communication.
• Now, telemedicine services can be made available to all irrespective of
time, place, social status or gender. Gujarat Govt.'s e-health
scheme,Aravind eye hospital's tele-ophthalmology unit at Andipatti, the
concept of village resource center (VRC) by ISRO are all examples of India's
steps towards pioneering in telemedicine services.

59. CHALLENGES OF TELEMEDICINE
1. HUMAN RESOURCES:
The 2006 World Health Report, “Working Together for Health”,
estimated a shortfall of 4.3 million skilled, motivated, and supported
health workers worldwide, with 57 countries having insufficient
numbers to provide even basic health services.

60. 2. POPULATION DEMOGRAPHICS:
• general trend toward increasingly older populations has been
occurring for at least 50 year.
• In Asia the next 20 years will see almost a quarter of the region’s
population needing “elder care”.

61. 3. AWARENESS AND KNOWLEDGE:
A common foundation of knowledge and understanding must be
developed, and the available technology then used to raise awareness
of users and decision-makers, and to provide training opportunities

62. 4. DOUBLE BURDEN OF DISEASE:
The developing world continues to face the burden of communicable
diseases, but now also must combat a significant rise in the prevalence
of noncommunicable diseases.

63. 5. POVERTY
6. TECHNOLOGY AVAILABILITY
7. ADJUSTING NATIONAL HEALTH PROGRAMMES WITH TELEMEDICINE
8. LEVEL OF EVIDENCE: Strong evidence of the impact of telehealth
anywhere in the world is lacking

64. 9. FOCUSSING ON TRUE NEEDS:
• The top health needs of each country (perhaps even subnational
region) differ, and this situation is dynamic with changes over time
being visible (creating the need for flexible solutions).
• Can telemedicine focus on behavioural modifications ?

65. CONCLUSIONS
• Telemedicine brings the world closer and assures quality and
universal access of health care.
• Services like tele-health, tele-education and tele-home healthcare are
proving to be wonders in the field of healthcare.
• Inspite of all the benefits of telemedicine, still its full implementation
is a challenge .
• Lack of awareness and availability of technology are the important
aspects which needs to be addressed.

66. BIBLIOGRAPHY
1. MOHFW GUIDELINES FOR TELEMEDICINE 2020
2. www.nmcn.in/webcase.php
3. Chellaiyan VG, Nirupama A Y, Taneja N. Telemedicine in India:
Where do we stand?. J Family Med Prim Care [serial online] 2019
[cited 2020 Nov 22];8:1872-6. Available
from: https://www.jfmpc.com/text.asp?2019/8/6/1872/261398