The first step in telemedicine is the telemedical diagnosis (or telediagnosis) based on information obtainable from medical images, blood, urine, and other pathological test reports . Usually, for diagnostic purposes, the doctor sends a patient for such examinations. The laboratory assistant takes the required X-ray or ultrasound images or carries out pathological tests and passes these images (or readings ) on to a radiologist/pathologist, who then makes an analysis and sends a report to a doctor. These manual actions are totally sequential and slow. This whole procedure can be made cooperative and faster if the images and data are stored in a database and these can be simultaneously retrieved by doctors , radiologists, and specialists in their offices or homes , using personal computers to make a cooperative diagnosis. This is the basis for telemedical (e-medical) informatics (Alfano, 1997; Coiera, 1997; Ganapathy, 2001; Gomez et al., 1997; Jameson et al., 1996; Kleinholz et al., 1994; Lauterbach et al., 1997; Mathew et al., 1999; Pham & Yearwood, 2000; Yearwood & Pham, 2000).
The principal aims of e-medical informatics are to:
Provide online services of patient records (medical and pathological databases) to medical practitioners and radiologists.
Provide primary specialist diagnosis, offer a second opinion, and provide pre- and post-treatment advice through e-mail.
Reduce the cost of imaging equipment, reduce delays, and increase the speed and volume of diagnosis.
Aid cooperative diagnosis and provide assistance for remote surgery.
Provide student/resident education.
Reduce professional isolation and increase collaboration.
Provide home care.
E-medicine offers the following advantages:
Provides health care to underserved and isolated areas so that we can make a better allocation and utilisation of health resources.
Since communication cost is much cheaper than the transportation cost, patients in remote areas can outreach physicians quickly.
Increases the speed of diagnosis and treatment, especially when used for teleradiology, cardiology, and psychiatry .
Allows access to speciality care using time-oriented clinical data.
Real-time monitoring of public health databases to prepare and respond during epidemics and biological and chemical terrorism.
The Internet can provide the following support:
Online health records
Pharmaceutical information and sales outlets
Online training for telemedical professionals
For an excellent treatment on the Internet and telemedicine, see Coiera (1997).
Thus the development of an integrated wireless (mobile) and wired-in networking environment for e-medical informatics can have a wide range of applications in health care for remotely situated areas. Such a computing environment has a particular relevance to vast countries (e.g., Australia, China, and India) with a widely distributed population, as well as to provide emergency medical assistance in areas of natural disasters and war-torn regions .
The prerequisites for a successful implementation of a telemedical system are:
Infrastructure: A suitable infrastructure of health-care providers, doctors, engineers, computing specialists, communication engineers , information technology professionals, and medical statisticians to analyse outcomes , and suitable outreach clinics with telemedical facilities.
Communication network: A reliable, inexpensive, readily accessible communication network from outreach clinics to hospitals , doctors, patients, and pathological laboratories.
Low-cost computers: Suitable low-cost hardware/software and a good communication bandwidth for transmission of medical data in different modes (radiological images, video images of signals, and text). While using wired in or wireless mobile devices and monitors , the effect of electromagnetic interference (EMI) and radio frequency interference (RFI) on data collection and transmission, and the side effects on patients (both physiological and psychological aspects) have to be taken care of so that improper diagnosis does not result.
Training facility: Training of personnel for providing proper maintenance of equipment and safety standards to patients.
Security, reliability, efficiency: Reliability, efficiency, security, privacy, and confidentiality in handling, storing, and communicating patient information.
In densely populated countries (e.g., India) if we want to keep the hospital bed to population ratio near the ideal ratio of one bed for every 500 persons, we will require more than 2 million beds. Assuming that we can build 1,000 hospitals with 200 beds every year, it will take 10 years to cater to the needs of the population in India (Ganapathy, 2001). Added to this is the annual rate of growth of population. The rate of growth in hospital beds to cope up with the increasing population is economically unsustainable and technically not viable since the number of medical specialists also cannot grow to meet this demand. It is intractable in reality. Thus in an ideal situation where every citizen needs to have an immediate medical attention unless we have some kind of telepresence of specialists and doctors. The use of telemedicine avoids unnecessary strain involved in travel and associated expenses, provides immediate attention and care, and can avoid hospitalisation and allow the patients to stay home, enjoying family support.
For example, in developing countries, congenital foetal abnormalities are major causes of prenatal mortality and morbidity. Suitable medical attention can be given at an early stage to help women, using the ultrasound imaging technology at remote places and transmitting the image either through telephone lines or the Internet. Chan et al. (2000) describe a real-time tertiary foetal ultrasound telemedical consultation system, using a standard integrated system digital network (ISDN), that operates in Queensland, Australia. This consultation system has gained acceptance from the clinicians and patients.
As another example, consider the home care for the elderly in developed countries.
Here telemedicine and telediagnosis play a different role. An aging population and rising health costs have created the need to care for more patients in their own homes. Hospitals without walls (e-hospitals, or virtual hospitals) provide for continuous monitoring of patients in certain diagnostic categories. The mobile communication and computing technology is vital to transmit information from a home computer through telephone lines and the Internet to appropriate medical professionals. Wilson et al. (2000) describe how to build such "hospitals without walls". The key technology used here is a miniature , wearable low-power radio that can transmit vital and activity information to a home computer, from which data is sent by telephone line and the Internet to the concerned doctors. This system has been experimented in Australia by the Commonwealth Scientific and Industrial Research Organization (CSIRO).
Thus telemedicine and telediagnosis are economic necessities for both the developing and the developed world, and the capital investment on a telediagnostic computing environment is of great benefit to society.
Although telemedicine has many advantages, the following challenges arise:
Reimbursement: How to charge patients (rationale), who will bear the cost of treatment, and how can the costs be reimbursed from health providers?
Costs: Who will support the ongoing costs?
Human factors: Will telemedicine gain wide acceptance from patients, doctors, governments , and politicians ?
Liability, malpractice: Who will be responsible for liability in case of wrong diagnosis and treatment, and how to avoid and eliminate malpractices?
Licensing: How to evaluate telemedical professionals and provide medical licenses?
Telecommunication issues: How to make an appropriate choice of the bandwidth requirement to make telediagnosis cost effective?
Interoperability: Software interoperability is a key requirement in telemedicine since different modalities of patient records are used, running on different platforms. How to achieve this feature?
Funding/sustainability: Setting up a hospital without walls (or a virtual hospital) requires capital expenditure and sustainable running expenses. Thus it is a national issue requiring cooperation of different agencies.
Evaluation/outcomes: The evaluation of the different diagnostic categories suitable for telemedicine and the outcomes of the treatment procedures require monitoring.
Confidentiality and security requirements: Security of patient data during storage and transmission are vital to safeguard confidentiality and privacy of patient information, as it can be abused or tampered to harm the concerned individuals. These criminal threats are more serious than the virus attack, overloading, and network disruption. Biometric authentication, (Nanavati et al., 2002) could be an answer in dealing with patient information. HIPAA (Health Insurance Portability and Accountability Act) has devised certain security measures in handling telemedical information (http://www.hipaadivsory.com/regs/securityoverview.htm).
We will not deal with these aspects as these are beyond the scope of the main theme of this chapter.