TELEMEDINDIA

Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS located in Lucknow, capital of Uttar Pradesh, a state in northern India, is a tertiary level referral academic medical center involved in teaching and training of super specialist medical professionals with 23 academic departments. It is the first tertiary care hospital in public healthcare sector in India to adopt Information Technology (IT) for healthcare delivery. The Hospital Information System (HIS) was implemented in 1998 to record, store, process and retrieve health data of all the patients. This software was developed in-house in collaboration with Center for Development of Advanced Computing (C-DAC), Pune.

Later in the year 1999, telemedicine activities were initiated in the form of testing the concept and the technology. The first research grant was availed of in the year 2001, which helped in creating an infrastructure for telemedicine. Regular tele-healthcare and tele-educational services were introduced for the postgraduate students of medical colleges of Orissa. These services have now been extended to educate the doctors of other medical colleges and community centers in other states. Besides, the Institute is associated with organizational activities and in policy initiatives of the government at the national and international levels. All the activities are in project mode and are being financially supported by government agencies such as Indian Space Research Organization (ISRO) and Department of Information Technology (DIT). Looking at the need of skilled manpower in the field of telemedicine and e health, a School of Telemedicine and Biomedical Informatics is coming up in the campus which is recognized as the National Resource Center by DIT to provide core infrastructure for research and development and trained manpower in various field of telemedicine.

Infrastructure at the SGPGIMS Telemedicine Center consists of several independent telemedicine workstations equipped with tele-radiology, tele-pathology and videoconferencing units with large display devices. It can carry out medical data transfer and videoconference with six remote locations simultaneously. The communication set-up consists of six Integrated Services Digital Network (ISDN) lines, one Ku band Demand Assigned Multiple Access (DAMA), one extended C band Very Small Aperture Terminal (VSAT) based on flexi DAMA supported by ISRO and fiber optic cable network supported by GAIL. All telemedicine sessions are real time and interactive in nature except some of the tele-consultations with rural nodes based in Uttaranchal state. The operation theatres of SGPGIMS are equipped with high-resolution video camera to transmit live telecast of surgical procedures. Two auditoria of 700 and 120 seating capacity are networked through optic fiber backbone to the telemedicine center to enable interactive live telecast of proceedings of seminars, workshops and conferences to different locations in India and abroad. With the completion of intra-hospital telemedicine network as an infrastructure component of upcoming School of Telemedicine, all HIS nodes will be made potential telemedicine nodes.

The national and international medical partners of the SGPGIMS Telemedicine Network include; all three Medical Colleges of Orissa located at Cuttack, Berhampur and Burla, two district hospitals of Uttarakhand State (Almora & Sirnagar), All India Institute of Medical Sciences, New Delhi, Postgraduate Iinstitute of Medical Education and Research, Chandigarh, Amritha Institute of Medical Sciences, Kochi, Christian Medical College, Vellore, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Ranguel University, Toulouse, France & Holy Family Hospital, Rawalpindi, Pakistan, Oregon Health & Science University, Portland, USA . The technical partners are Indian Space Research Organization, Bangalore, Center of Development of Advanced Computing, Pune & Mohali and Online Telemedicine Research Institute, Ahmedabad.

All the telemedicine activities are now carried out in the newly established School of Telemedicine & Biomedical Informatics. The facility is being run by Project Staff under the supervision of a Nodal Officer who is guided by SGPGIMS Telemedicine Program Committee on policy matters. Faculty members of different departments take part in daily telemedicine activities on a schedule manner.

From the beginning in 1999, SGPGIMS is actively involved in tele-heath care activities and has developed following modules in this area.

It is helping physicians and health care specialists at partner hospitals to get help from the SGPGIMS experts to diagnose and treat patients over distances using telemedicine technology. In September 2000, the first experiment was carried out using store and forward technology on Public Switched Telephone Network (PSTN) to exchange electrocardiogram (ECG) between District Hospital, Pithoragarh, Uttarakhand and SGPGIMS, Lucknow, Uttar Pradesh located 275 km apart. The exchange of video clippings of 30 patients, typed and hand written notes ultrasound and radiographic images, and audio clippings provided images of satisfactory quality. Later in the same year similar experiment was carried out with Balrampur and Civil Hospitals located in Lucknow city. In August 2001, SGPGIMS initiated a project by linking one of the medical colleges of Orissa – SCB Medical College, Cuttack situated 1500 km away from Lucknow, through 128 kbps ISDN, to study the impact of telemedicine technology in providing remote super-specialist medical consultation to physicians. To evaluate the success of this program an audit was carried out in March 2002, at the end of seven months from the beginning of the Telemedicine sessions. Later in March 2003, with the support of ISRO and Orissa state government, the network was extended to the remaining two government medical colleges in the state: the VSS Medical College, Burla and MKCG Medical College, Berhampur. Another state-wide telemedicine network project started with the support of Uttarakhand state government in April 2004 in which two district hospitals of Uttarakhand state in the hilly region got networked with SGPGIMS for tele-consultation services. Both real time and store and forward technology were used to provide these services.

Tele-follow-up clinics in the Departments of Rheumatology, Endocrine Surgery and Nuclear Medicine were established in 2004 to help the patients from the state of Orissa who had undergone primary treatment at SGPGIMS need not come to Lucknow for their follow-up. It has made an impact in terms of saving their time, money and efforts by avoiding frequent physical follow-up visits to Lucknow. Their follow up is done in real time using telemedicine technology.

Doctors of SCB Medical College, Orissa who refer patients to SGPGIMS discuss the patients with the consultants of SGPGIMS before referring the patients to SGPGIMS. This activity was started by Department of Endocrine Surgery in October 2004.

Thyroid cancer patients of Orissa who have been operated there and need radio-iodine scan and therapy are discussed with Nuclear Medicine Physicians at SGPGIMS to plan post-operative adjuvant therapy. Schedule of appointment is fixed depending on the availability of isotope. Also, such patients of Orissa who have been operated here also schedule their appointment for adjuvant therapy.

Tele-Education should be understood as the development of the process of distance education (regulated or unregulated), based on the use of information and telecommunication technologies, that make interactive, flexible and accessible learning possible for any potential recipient.

Different modules of tele-education can be practiced depending upon the requirement and need of the remote side such as tele-CME, tele-conference tele-consultation, surgical treatment planning , tele- mentoring ,lectures, case discussion etc.. Tele-education can be planned at different levels.
SGPGIMS practiced its tele-education program for postgraduate students, healthcare professionals, paramedical staff and share knowledge with the peer institution are summarized below

From September 2001 to March 2002, SGPGIMS conducted its distance medical education program for the post-graduate students of SCB, Medical College, Orissa state, in eastern part of India, linking through ISDN. This was the first distance education programme for post graduate medical students offered by a territory care medical center in India. Facilities of various Departments such as Endocrine Surgery, Surgical Gastroenterology, Urology, Pathology, Rheumatology, Radiology, Nuclear Medicine, Neurosurgery, Neurology took part in it. Encouraged with the outcome of this pilot project based on the feedback from the users, in March 2003, SGPGIMS again revived and extended this program to two other medical colleges i.e. VSS Medical College Burla and MKCG Medical College Berhampur of this state. Problems in management of difficult and complicated cases faced by the doctors in Orissa were clarified and illustrative cases seen at SGPGIMS were shown to the postgraduate students and doctors of Orissa for their knowledge update.

With an aim to develop and improve the professional career and consultation skills of the rural and remote doctors, SGPGIMS used telemedicine technology in various projects. In these programs, the specialties and topics chosen for these programs were based on the needs and demands of the users at the remote end which they thought would be helpful in their day-to- day clinical work.

From July 2003 to October 2004, with the help of National Informatics Center (NIC), Delhi we carried out a project for the doctors of peripheral and remote hospitals of North East states of India to make them aware of the recent advances in managements of the patients. This Tele-education sessions from SGPGIMS was telecast interactively to eight North Eastern states head quarters and broadcasted to 450 Community Information Centers located in the same regions through NIC hub as a monthly session using ku band satellite communication link.

Similar activities performed district hospitals of Uttarakhand at Almora and Srinagar in the remote hilly areas through ISDN media and District Hospital of Raibareli, through fiber optic cable network.

This teaching and training activity started for the nurses and hospital administrators of district hospitals of Almora and Srinagar and later extended to the District Hospital, Raibareli and medical colleges of Orissa to improve the patient care skills and healthcare facilities in these hospitals.

Sometimes the specialists also need to discuss or share their knowledge with the specialists of other centers of the same level. For this purpose, SGPGIMS Telemedicine Center established contact with other reputed national and international institutions. In this program, the doctors of both the institutions share their experiences and knowledge and discuss the complicated and interesting cases.
National – In 2004, SGPGIMS got linked to Amritha Institution of Medical Sciences (AIMS) Kochi, Kerela, an upcoming tertiary level institution in south India, through VSAT. The departments of Endocrionology), Endocrine Surgery, Surgical Gastroenterology and Gastroentrology are actively participating in this program once in a month. Similarly from October 2005, department of Urology established contact with two premier institutions of the country, All India Institutes of Medical Sciences (AIIMS), New Delhi and Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh through point to multipoint connectivity. Other Departments involved are Nuclear Medicine network with AIIMS New Delhi and Endocrine Surgery) with Christian Medical College, Vellore.

International- SGPGIMS also established contacts with Ranguel University, Toulouse, France, Holy Family, Hospital, Rawalpindi, Pakistan Oregon Health & Science University, Portland, USA through high bandwidth ISDN. The Department of Endocrine Surgery and Surgical Gastroenterology participated in these programs. These programs give an international recognition to India in the field of medicine and technical advancement.

From time to time various departments of SGPGIMS organizes Continuing Medical Education (CME) programs to update knowledge. The entire proceedings of these CMEs were transmitted to the networked medical colleges and institutions. On an average 15-20 faculties and medical students participated at the remote locations. The video lectures of eminent persons of international fame received at SGPGIMS from abroad were also transmitted to theses network partners during these Tele-CMEs. This distant education program has immensely benefited the postgraduate students and doctors of these medical colleges in enchancing their knowledge and keeping them abreast with the recent advances and research in various super-specialties and treatment of the patients. Besides this, another advantage of this program is that the faculties and the students need not travel to attend these CMEs, they can perform their routine work and attend the sessions of their choices.

Recently SGPGIMS started receiving weekly sessions of clinico-pathology conference held at PGIMER, Candigarh, located at a distance of 900 km, in which more than 5 faculties/residents of various departments participated. Similarly, clinical grand round, a weekly academic program conducted by the various departments of SGPGIMS is being transmitted to Rohtak Medical College, Rohtak located at a distance of 550 km.

In March 2004, a tele-mentoring trial by the department of Endocrine Surgery was carried through satellite based telemedicine network. Endocrine Surgeons at SGPGIMS assisted surgeons in AIMS, Kochi located at a distance of 2500 km to successfully operate a patient of primary hyperparathyroidism who had two unsuccessful operations in the past. Besides broadband tele-communication, excellent picture of the surgical field was grabbed with high resolution video camera and exchanged in real time through video-conference system along with step by step interactive discussion.

Every year thousands of pilgrims visit Kailash Mansarover located in the Himalayan mountains in the Chinese territory to perform religious rituals. Weather is extremely cold in the morning and evening with temperature ranging between 0 to 40 Celsius and terrain is unfavorable and difficult (5029 Meter from sea level at Lepulekh Pass). Each group of pilgrims was accompanied by one doctor. At the border check post, the pilgrims undergo medical checkup by the doctors of Indo Tibetan Border Police (ITBP) hospital. In spite of this, some pilgrims may develop high altitude sickness (loss of appetite, fatigue headache, nausea, dizziness, palpitations, sleeplessness, shortness of breath) and heart problems for which an immediate ECG is required. In June 2001, an SGPGIMS telemedicine team comprising of a doctor and one telemedicine engineer joined the 12th batch of pilgrims at Pithoragrah base camp and accompanied them through out their trek till the Indian border. On the way they stopped at the camps located at Sikha, Gala (2375 Meter), Bundhi (2740 Meter), Gunji (3500 Meter), Nabidhang (3987 Meter). From all these points during the Kailash-MansarovarYatra, ECG was transmitted successfully to SGPGIMS for tele-consultation through Inmarsat satellite. This experiment was carried out to test the technical feasibility of online transmission of patient health data such as ECG from high altitude.
SGPGIMS carried out another telemedicine application project during the Maha Kumbh mela held from January 3rd to 26th February, 2001 at the Sangam, Allahabad to find out the benefits of telemedicine technology over and above the traditional health care delivery system. At the Maha Kumbh Mela, large congregation of people (approximately 10 million people) occurs at one time. In such a large congregation a number of infectious ailments and accidents like fracture, burn and drowning etc occur which require immediate help. In normal course temporary hospitals set up at the mela ground were the only healthcare infrastructure provided by the state government which does not have the specialist expertise to handle all kinds of medical problems. Further, public healthcare monitoring such as water quality, infective disease cases were carried out from the state headquarter at Lucknow. So a telemedicine network with 128 kbps ISDN was set up connecting five locations which included mela site field hospital, local medical college at Allahabad and SGPGIMS, public health department and Mela monitoring cell at Lucknow located 300 km away. Regular exchange of health related data and video-conferencing were carried out between these nodes. Continuous monitoring of water samples from different areas spread over several sq km helped to prevent water borne diseases and epidemic outbreaks.

SGPGIMS has been a partner in development of indigenous software (Mercury & Sanjeevani) for Telemedicine and its application in collaboration with C-DAC, Pune and Center for Electronics Design and Technology of India (CEDTI), Mohali (Fig.2). The software which is inter-phased with medical accessories like tele-pathlogy, tele-radiology, tele-cardiology and video-conferencing is deployed at three premier institutes of India

Mobile tele-hospital projects was launched in the middle of 2001 in collaboration with Online Telemedicine Research Institute, Ahmadabad. It was aimed at providing telemedicine facility in a mobile setting which can find application in emergency health care (Tele-ambulance) and rural health care (Mobile Tele-hospital) and disaster situations (Portable suitcase telemedicine module). These units can cover emergencies, disaster and routine work in villages where frequently large congregation of people occur in connection with melas, market and other social activities. It can also provide services of general and specialist checkup as well as vaccination and health awareness among rural and urban population. The prototypes have been developed and tested successfully in the field. Commercial production is awaited.

d). Development and Maintenance of a e-Seminar Web Portal (www.telemedindia.org)

SGPGIMS is in the process of creating web portal with support of Sony, Japan, a project of public private partnership. This web portal is going to be a knowledge base on telemedicine and e Health in India.

5. Participation in Telemedicine awareness programs and national telemedicine policy making initiatives:

In order to develop awareness of health care providers, policy makers and public on the utility of telemedicine in modern day health care, SGPGIMS has been participating in health exhibitions and organizing conferences on telemedicine at national and international level. The entire proceedings of the conferences were transmitted to some medical colleges of India and abroad. It has played an important in the formation of Telemedicine Society of India.

SGPGIMS has been involved in the design, development, deployment and project management of the Orissa, Uttarakahnd and Uttar Pradesh telemedicine network projects in collaboration with its technical partners. Internationally it has also advised the governments of Nepal as an ITU telemedicine expert and Maldives and North Korea as WHO expert.

SGPGIMS, has taken up the initiative to set up a School of Telemedicine & e health in its campus with the support of Uttar Pradesh government to start degree and degree courses in this field. This school is also recognized as National Resource Center for Telemedicine by DIT. It has also support creation of laboratory infrastructure to carry out inter-disciplinary research in the field of Health IT. The disciplines which are going to be created in this School are Telemedicine, Hospital Information System, Bioinformatics, Medical Multimedia, Medical Knowledge Management, Artificial Intelligence in Medicine, Virtual Reality and Robotics in Medicine. The objectives of the school are creation of various resource facilities for imparting structured training program towards capacity building in e health sector, research and development, providing consultancy to government and private healthcare organizations and fostering collaboration with technological and medical universities in the country and abroad.
A batch of five trainees from Maldevis sponsored by WHO visited School of Telemedicine and Biomedical Informatics to receive training in pre-schedule manner. A “SGPGI Telemedicine operating manual” prepared under National Resource Center project and provided to trainees.

8. Policy Initiatives:

SGPGIMS participated in various policy initiatives to government of India in the field of telemedicine. It helped the government in the planning of various telemedicine projects at the national level. It is the member of National Telemedicine Task Force constituted by Ministry of Health and Family Welfare. It has also contributed to the policy initiatives of various international societies and organization, Asia Pacific Tele-communications, United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP), on telemedicine.