Indian Space Research Organisation
Towards Telemedicine for Primary Care
Dr. D.Gopinath, Dr. Nandakumar


Introduction
Today we see advancements in many fields like LT., Communication, Processing and Equipments. The new challenge is to channelise the impressive gain being madein the Non-health sectors into issues of 'Community Health' or 'Public Health'. A multi-disciplinary consultation group comprising specialists from Primary Health Centre (PHC) System, Medical Specialities and ISRO was formed to address this issue & the results of brainstorming are highlighted in this article. The participants were unanimous in theiropinion that it was about time we adopted innovations in the ftled of Information and Technology for the betterment of health caredelivery systems especially at the Primary Health care level. The participants suggestedthat a comprehensive plan of action had to be evolved to deliver an integrated-package of "grass-root" Telemedicine services, including limited teleconsultation, simple telediagnostic, telecoordination and teleeducation. Additionally the system may be employed to improve the quality and efficiency of our existing MIS (Management Information Systems).

The Challenges
Recent decades have seen an unprecedented growth in information and communication technologies (ICTs), ushering in what is commonly referred to as the 'Information Age'. The challenge is to reach this development to the hundred thousand villages and 3000+ towns and cities. The new challenge is to channelise the impressive gains being made in the Nonhealth sectors into issues of 'Community Health' or 'Public Health' and the need is 'how do we operationlise Telemedicine inPrimary Health Care'.

Primary Health Care has been defined as essential care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the country can afford and maintain at every stage of their development in the spirit of self-determination. Equity (Accessibility, Availability, Affordability) along with Inter-sectoral Co-ordination, Community Participation and Appropriate Technology have been described as the principles and pillars of Primary Health Care. The 23,000 Primary Health Centers and their private counterparts the 'Clinics' (as yet not completely enumerated) form the back bone of the Health Care service delivery system. While evaluating the Indian Primary health care system many critical aspects can be listed. However, it still largely remains the main source and many a times the only source of medical care. In the study done at one of the primary health centres in the year 2003, 47% of the population depend on the government PHC for their health care needs. Also, the same study points out that 14% of the patients travel 9-15 kms, 31% travel 35-45 kms and a huge 55% travel more than 55 kms for accessing secondary and tertiary services.

Telemedicine for Primary Care
Telemedicine as we understand, it has a great potential to enhance the functioning of the existing health care delivery system, especially when distance and thus, access to health care is a critical factor.

The following major functions of the Primary Health Centre were recollected as enunciated in the Bhore Committee (1946) report:

  1. Medical Care
  2. Maternal & Child health(MCH) & Family Planning
  3. Safe water supply and basic sanitation
  4. Prevention and control of local
  5. Endemic diseases
  6. Collection and reporting of vital statistics
  7. Health education
  8. National health programmes
  9. Referral services
  10. Training
  11. Basic lab services
For Telemedicine to be successful, a well synchronized team has to be functional. One of the significant advantages in the Indian scenario is the well organized health caredelivery system. The three tier system comprising Primary, Secondary and Tertiary care is well in place and has been functioning with reasonable efficiency for several decades now: The District health and family welfare officer (Bangalore District) mentioned that presently there are more than 100 operational Community Health Centers, fully equipped with both resources and necessary man power, and use of these centers in areas of specialist care is most feasible at the primary level such as Primary Health Center and Sub Center. Integration of this targeted, need based and focused technological intervention requires a well planned strategy such that minimal changes are made to the existing system.

A comprehensive plan of action had to be evolved to deliver an integrated-package of "grass-root" Telemedicine services, including limited teleconsultation, simple telediagnostic, telecoordination and tele-education. Additionally the system may be employed to improve the quality and efficiency of our existing MIS (Management Information Systems). This will thereby provide a workable model of Telmedicine which is representative of the actual need in the field.

The telephone has always been and will continue to be an important means of providing health care at a distance. However, if the prime elements of clinical consultations are listening and observing, a telephone conversation only provides the verbal element of the process. Recently, the visual element has also been provided in the form of technologies for the transmission of visual as well as auditory signals. Major areas of application of this technological innovation identified are
  • Routine consultation with specialist for any major illness - bringing specialist in close proximity to the distant community.
  • Emergency Obstetric care.
  • Emergency trauma care.
  • Any acute illness.
  • Follow-up for Chronic illness
Telemedicine Equipments
Though the specific list of equipments required could be made only on the basis of the services offered, from a general consensus, it is felt that the following requirements would be required initially:
  • Telephone, web cam, computer, digital camera and man power to use it
  • Slit lamp / Ophthalmoscope
  • Ultrasound Scanning machine
  • Emergency kit, Pulse Oxymeter, Glucometer, Haemoglobinometer, Digital X-ray, ECG machine
Also it was suggested that basic facilities for Hematological investigations such as blood grouping and typing, cross matching should be made available to supplement case management strategies during emergencies.

Continuity of patient care is enhanced when the patient, primary care physician, specialist and family members are involved. Certain issues of concern are that of patient compliance and satisfaction. Though several earlier endeavours have proved the efficacy of the system; the actual outcome would be evident with time. Another issue is the skill levels of the basic health care providers to perform certain complicated procedures. The solution to this is to ensure adequate training and ope rationalizing the use of available standard protocols for case detection and management at different levels.

Telediagnostics
Another area of potential application is that of telediagnostics. As most of the infrastructural requirements for basic diagnostic tests are already in place in our existing health system, minor value added changes in terms of additional equipments and technology to transmit either test data or results to the concerned specialist for opinion would enhance the quality and efficiency of the existing system. It would be based on the services provided at each level and it is identified that with these facilities the system may be useful in:
  • Outbreak investigations, specifically for the elucidation of etiological diagnosis
  • Using information at hand and provide advice to thwart future outbreaks
  • To help clinicians to arrive at the most probable diagnosis
  • To assist in infection control.
It is also important that the available technicians could be trained to operate basic facilities and that the lab facilities could be tailor made to the requirements of the concerned specialists, and once the actual requirements are specified by them, infrastructural requirement and suitable manpower requirement can be suggested. The basic equipment required for the initial phase would be Photomicroscope with digital image transfer capability.

Health Education
One of the most important concepts of primary health care is that of health education. Awareness forms the basic crux of any efficient health care system. The Telemedicine may be used efficiently for enhancing the effectiveness of IEC (Information, Education and Communication) strategies under several national and local health programmes. This would not only increase the knowledge of the intended beneficiaries but also help the programme managers to deliver the services effectively. Another component is that of Continuing Medical Education for the health care providers. In this era of constant change, medical field is undergoing rapid transformations and the health care providers must be kept abreast of the recent advances and development. Also skill imparting sessions may be undertaken via Telemedicine and improve the quality of health care.

Management Information System
Vast amount of data is generated at various levels of health system and due to several factors; presently efficient utilization of this for system improvement is still rudimentary. An efficient data and information management may be evolved to help the health care managers to plan, implement and evaluate programmes tailor made to the prevailing ground realities.

Certain issues of concern, such as improving the power situation (in order to ensure uninterrupted supply), training of the users in operating and maintenance of the equipment (including basic troubleshooting) and importantly elucidating clear cut guidelines with respect to medico-Iegalethical issues for the use of this technology.

Conclusion
With these in mind, it is concluded that delineation of major morbidity pattern in the intended areas of application and the existing infrastructural facilities for delivery of health care is essential. Once the macro picture of the situation is analyzed the micro-planning for implementation may be evolved.

Subsequent interactions with concerned specialists would help in developing a workable plan of action for successful accomplishment of this realistic endeavour of bringing the Telemedicine for primary health care. The author acknowledges the contribution of the members from MSRMC, Karnataka govt & ISRO who participated in the discussion & provided valuable suggestions.