Indian Space Research Organisation
How to setup a Telemedicine center & Telemedicine Devices and Equipment
Dr. D.Lavanian


Abstract
Setting up a Telemedicine center has always been a critical component of any Telemedicine project. Improper planning can convert a seemingly simple task to an exceedingly complex project. This paper talks of the methodology to be followed and the planning required to successfully setup a telemedicine center followed by a discussion on the kind of devices and equipment that can connect to telemedicine systems and the planning required to put them together and make them work satisfactorily.

Introduction
Telemedicine (TM) is now a proven technology that is capable of taking this dream of "healthcare for all" closer to reality. Being dependent on the synergy of information technology, medical devices, connectivity,communication technology and medical manware, the implementation and operationalmanagement can be complex and prone to failure - if not planned well.

Some of the barriers coming in the way of quick spread of this technology are as follows:

  • Improper selection
  • High of and costs equipment infrastructure
  • High costs of maintenance
  • High training costs
  • Complex training requirements
  • Lack of/poor connectivity
  • Complex implementations
To avoid failure and ensure a foolproof implementation standard methodologies and Standard Operating Procedures (SOPs) need to be followed.

TM implementations will generally require the client and the service provider to plan & address the following process:
  • DefIning Project goals and objectives
  • Pre-implementation phase
  • Implementation phase
  • Post-implementation phase
Defining Project goals and objectives:
In this stage, the client's inputs are collected as to form the scope and goals of the project. This is because in certain cases the client desires to put up a Telemedicine centre (TMC) but is not aware of the true potential or issues involved. It is advisable to have a meeting and also inspect the local site with the technical team, to collect inputs that would help to:
  • Assess the requirement, viability and funding
  • Select the appropriate business plan (if required)
  • Assess demographics of the location
  • Selectthe appropriate site
  • Assess manpower requirements
  • Select the appropriate form of connectivity
  • Select the appropriate equipment
  • Check with vendors for availability and delivery schedules of hardware
  • Plan the logistics
  • Document responsibilities of the client
  • Work out the time lines for the project (Gantt chart)
  • Plan for delays and exigencies
  • Embed planned and surprise checks in the plan
  • Plan for training of staff
  • Plan for a hand holding period
  • Plan for operational management where necessary
  • Create a backup plan
All of the above would be put together into a 'Project Proposal' that would be handed over to the client.

Based on the Proposal the client would either agree to the same or request for some changes or clarifications.These issues can be resolved either through email, videoconferencing or a face-to-face meeting. On all issues being sorted out, a committee could be setup to oversee the implementation with representatives from both sides from medical, technical and administrative areas.

Once the Go-ahead is received and the MOU signed, the project moves into the Pre-implementation Phase.

Pre-implementation phase:
In this phase the client is given a detailed roadmap of the project and appraised in detail, of his (client's) responsibilities. These would include:
  • Steps to be taken for readiness of the local infrastructure like room, air-conditioning, power, internal setup, approach and positioning of the room vis-a.-vis the X-ray, CT scanner, MRI, Ultrasound etc.,
  • Formal documentation to be raised for transport of equipment and their utilization.
  • Support required from him( client) for interactions with the local government and agencies.
  • Allocation of a local rep, doctors, TMC administrators, X-ray technicians, etc for the TMC.
  • Allocating time for the trainingof the above staff.
The telemedicine implementer would carry out the following actions:
  • Allocate staff and resources for the project as per the project plan
  • Place orders for equipment to vendors
  • Apply for required permissions for connectivity and other allied requirements.
  • Monitor progress of readiness at site.
  • Carry out software customization, if part of the project.
  • Prepare customized Training Manuals if required.
  • Carry out testing, integration and fitness certification of hardware and software.
  • Integrate and 'Hot' test the complete application through connectivity available in the central office.
  • Connectivity would be made to the live receiving Telemedicine center or to a test site.
  • Debug the issues that may arise.
  • Test security protocols
  • Train the client's TMC staff on the application as per the Project schedule.
  • Dismantle and pack equipment for transportation.
  • Station one team member at site to inspect, advice the client and certify readiness of the TMC.
  • Suggest alternatives in case of issues
  • Certify site ready for implementation.
  • Collect necessary documents and permissions for delivery of material to the client site.
Implementation phase:
In this phase the following activities take place:
  • Delivery of the equipment
  • Site readiness
  • Installation
The local client staff earmarked to run the center should be included in the implementation to observe and note the procedures being followed. A daily log of actions carried out, will help the process.

Generally the Video conferencing equipment (VCE) should be first setup and connected to the connectivity pipe (either ISDN, broadband or VSAT). This ensures instant communications with the TSP and the specialist hospital and also acts as a help desk of the TSP. The rest of the unpacked equipment should be assembled component by component starting with the server/ desktop computer. At each stage functionality is to be checked. The interior setup of the telemedicine center can vary from place to place but in general the following concepts should be kept in mind. A suggested plan for a TMC is given as annexure 'A' to this paper.

Telemedicine Centre
The Telemedicine Room should have at least 250-450 Sq ft of carpet area. The actual area required would depend upon the medical equipment that is being planned to be interfaced with the Telemedicine set up. The room should be, if possible, located in that part of the hospital, which has less traffic and is less noisy.

General Requirements
Telemedicine Centre:
  • The Telemedicine Room should be for sufficiently big to accommodate placement of two computers with 17" monitors each, a printer, and connectivity (VSAT indoor) equipment rack and few chairs. Telemedicine Room at Patient End should be slightly bigger to accommodate Medical diagnosis equipments viz X-Ray Scanner, Pathological Microscope, a bedfor taking ECG. If the video conferencing equipment is also to be used for CME, then bigger Room may be required depending on the number of participants and also to accommodate a bigger ~ say 29".
  • Doctor End Room should be at least 12' x 20' and Patient End Room at least 15' x 30'. If the patient Side Room also has an ICU then minimum space required for the Room is 1500 Sq. Feet. In case of Medical College Hospitals a Standard Class room size of at least 30' x 50' is required with good provision for placement of Audio/ Video System as a virtual classroom
  • Room Temperature should be Maintained between 18 to 25 deg C, Preferably using split A/ c, for less background noise during video conferencing.
  • Room should have electrical outlets for connecting various equipments and a very good earthing pit. Five 15Amp Sockets for UPS, and five 5Amp Sockets for other diagnostic equipments are advised, with proper arrangement of the Power Supply during emergency.
  • The UPS should be atleast of 3 KVA capacity depending on the equipment load.
  • Shall have good acoustics, using sound absorbing panels or heavy curtains, for noise free environment during video conferencing.
  • The curtains and walls should be light blue or gray in color, to give good contrast/view for video conferencing.
  • Room should have good flooring, preferably vinyl or ceramic floor, to reduce noise.
  • Room should have good illumination, to get good picture quality for video conferencing.
  • Wherever VSAT is used, antenna Size is 1.8 meter in diameter for Remote end & 3.8 meter for speciality end and weight is 500-2000 kg. Ideally the Antenna should be located at top of the building and should be within distance of 40m (Cable Length) from the Telemedicine Room
  • Antenna should have unobstructed field of view to the Satellite, and no LT/HT Power lines should be near the Antenna or in its field of vision.
  • Wherever it is not possible to place the antenna on the building, it should be mounted on floor around the Hospital on a firm concrete base. In such cases, appropriate protection should be provided to prevent mishandling of the antenna elements.
Installation and Training
Once the equipment have been completely assembled and tested offline with the software, connectivity with the test center at the Implementer's HQ should be done. As the Video Conference Equipment (VCE expo) would already be functional there would be an assurance of connectivity for the data section. At least 10 test specialist consult requests should be sent using different sizes of fIles and the results sent tested for errors. This would confirm readiness of the 'Store and forward mode'. Testing Desktop Video-Conferencing (Vq for quality, clarity of sound and picture and frame rate, should follow this. Real time viewing of data from equipment like ECG, X-Ray scanner, Microscope, Ultrasound, etc should be tested next. Finally a combination of live VC with high resolution data capture and transfer should be tested.

Once the equipment is live, the local staff can be trained by the TSP. The client's staff should then carry out similar dry runs using test and non-patient data.

Post-implementation phase
This is the phase when the TSP staff collect the 'Sign Off' and 'handing over'. They generally have a 'Hand Holding' period when they watch the client's staff carry out the tasks, on their own and suggest corrections if required.

Devices and Telemedicine Equipment
Telemedicine Software from a mature company is generally well designed and capable of connecting to most equipment. However certain equipment connect better as compared to others. Hence as long as the right hardware has been selected the software causes no glitches.

The training requirements would be the same for the software, but based on the equipment added to it, each piece would have its own training program. The learning curve for both the trainers and the trainees becomes easy. Even connectivity requirements become less if the equipment used are optimized to produce faster and leaner output. So let's first look at the kind of equipment required for a Telemedicine station and later at the selection criterion and procedures.

Telemedicine equipment can broadly be divided into the following components:
  • Information Technology (IT) hardware
  • Connectivity Hardware
  • Video conferencing hardware
  • Medical Hardware
IT Hardware: IT hardware mainly comprises the equipment, which helps run the software, interface with the user, connect to the medical devices, store data securely and exchange data when required. This would include computers, multimedia devices, scanners, security devices, daughter boards and hand held devices.

Connectivity Hardware: Devices required for connectivity would include items like modems, VSATS,routers, hubs, switches and structured cabling.

Video Conferencing Hardware: These are equipment that permit full screen Tv, plasma TV or Projection Tv, live two way audio and video conferencing.

Medical Hardware: This would comprise all the clinical instrumentation that would be attached to the Telemedicine system to capture data from the patient. The list of equipment could be enormous but those commonly used are as follows:
  • Digital 12 lead ECG
  • Digital BP
  • Digital glucometer
  • Electronic stethoscope
  • Digital microscope
  • Digital PFT
  • Pulseoxymeter
  • Electronic ENT and Fundoscope
  • Skin camera
  • Multiple parameter monitors
  • Doppler Ultrasound
  • CT scanner
  • MRI
The actual list of devices/equipment is project/ site specific and the nu~ber of modalities planned to be supported from the TMC.

Equipment as above comes in various configurations, sizes and shapes and capabilities and varying costs. Based on the necessity and affordability, a carefulassessment has to be done regarding each instrument to ensure right fit.

Some of these considerations are - need for equipment, DICOM/Non-DICOM requirements, interface options, cost effectiveness, vendor support, running costs and maintenance etc. Details of some instruments are provided. Refer Annexure 2 for detailed and recommended specifications of major equipment & devices.

Based on the assessment of the factors above, the next step would be to select the equipment. A thumb rule would be to select standard certified equipment that that would not be become obsolete for at least 2 years.

Conclusions
A Telemedicine setup can be painless, simple and economical if the right, SOP's are followed and if the right equipment is selected and right protocols adopted. Thjs would go a long way in bridging the Rural- Urban healthcare divide.

This paper gives broad overview of the whole process and the author makes it clear there is obviously much more to it as each requirement as well as implementation is unique in its own way.

References
  1. http://www.doctorndtv.com/feature/detailarchivefeature.asp?id=56 quoting Dr. Shyam Ashtekar The author of 'Health & Healing: A Manual of Primary Health Care'
  2. http://www.emergic.org/collections/tech_talk_transformin~rural_india.html
  3. http://www.aarogya.com/Legalities/telemedicine/advtges.asp#barr
  4. http://www.doctorndtv.com/feature/detailarchivefeature.asp?id=56 quoting Dr. Shyam Ashtekar The author of 'Health & Healing: A Manual of Primary Health Care'
  5. http://www.emergic.org/collections/teeh_talk_transformin~rural_india.html
  6. http://www.aarogya.com/Legalities/telemedicine/advtges.asp#barr