Telemedicine. SIV 864: Special Module on Multimedia Applications. Sakti Srivastava, MBBS, MS

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1 : Special Module on Multimedia Applications Telemedicine Sakti Srivastava, MBBS, MS Adjunct Professor, School of IT and Centre for BioMedical Engineering Indian Institute of Technology, Delhi

2 Definition Telemedicine Telehealth At a distance Delivery Preventive of and clinical promotive service

3 The earliest attempts.

4 The first modern attempts

5 The next milestone

6 The Internet changed everything

7 The Physician of 2020?

8 The Physician of 2020! Electronic Medical Record Digital Imaging Telemedicine Treatment protocols Lab tests Patient Monitoring Computer-based teaching Simulators Decision Support Robotic Surgery

9 Building Bridges Needs Medical Applications Technical Solutions Speak the same language Understand each other Work together

10 The coming together of Education experts Physicians Computer professionals Graphic designers Industry Engineers Governments Voluntary organizations

11 Types Synchronous Real-time Asynchronous Store & Forward

12 Synchronous Telemedicine Real-time Requires both parties to be present at same time Telephone consultation Videoconference Extendable peripheral devices (tele-stethoscope, tele-otoscope) High bandwidth utilization

13 Synchronous Telemedicine (2) Client-server or peer-to-peer architecture May be recorded or not Phone lines / ISDN / Satellite / Broadband

14 Asynchronous Telemedicine Store and Forward Does not require both parties to be present at same time Capture text / audio / image / bio-signal data Requires some form of electronic medical record (EMR) Low bandwidth utilization

15 Asynchronous Telemedicine (2) Postal system / Letter / Fax / Network connectivity Databases Scheduling of offline activity

16 Standards Medical Standards International Classification of Disease Clinical Procedural Terminology Unified Language of Medical Sciences Technical Standards Accredited Standards Committee (ASC) X12N Digital Imaging and Communications in Medicine HL7 International Telecommunications Union H.320 Association for Advancement of Medical Instrumentation

17 Non technological issues Medical Issues Security and Privacy Clinical Quality Assurance Education and Training Implementaiton Issues Business models / reimbursements Portability and Inter-communicability Reliability / Technology support Scalability

18 Case Study

19 Healthcare Scenario in India India spends <1% GDP on health Urban/Rural mismatch of health professionals and population >70% rural population Most lack access to basic health facilities

20 Telemedicine in India Aravind Hospitals Teleopthamology Network Apollo Hospitals Aragonda Project OTRI (Online Telemedicine Research Institute) Asia Heart Foundation OncoNet (Kerala) Common Service Centers e-governance

21 Telemedicine in India VSAT based (ISRO) Broadband based (BSNL) High cost (setup and maintenance) High technical expertise Low bandwidth Limited scalability

22 Continuing challenges Remotest of remote No connectivity Limited infrastructure Bottom of Pyramid (<$1 per day) Landless farmers, illiterate

23 Criteria Inexpensive and low maintenance Easy and quick to setup Robust and durable Minimal new technology usage and skills requirement User-friendly, able to cope with infrastructure Support large datasets and scalable

24 Our proposed solution Asynchronous (Store & Forward) Delay tolerant network (DTN) Large datasets Several unique features Highly scalable

25 Application overview Kiosk- PC

26 Case Flow 1 Health Care Worker DICOM D1 (Neuro) Dispatcher D2 (Pediatrics) Radiology Equipment Primary Healthcare Centre (Rural) D4 (Ortho) D3 (Ortho) New Case Submission Path Reply from Doctor Internet Region

27 Case Flow 2 Health Care Worker DICOM D1 (Neuro) Radiology Equipment Primary Healthcare Centre (Rural) Dispatcher D4 (Ortho) D2 (Pediatrics) D3 (Ortho) New Case Submission Path Reply from Doctor Internet Region

28 Case Flow 3 Health Care Worker DICOM D1 (Neuro) Radiology Equipment Dispatcher D2 (Pediatrics) Primary Healthcare Centre (Rural) New Case Submission Path D4 (Ortho) D3 (Ortho) Referral to another Doctor Reply from Referred Doctor Internet Region

29 Design Overview DICOM Interfacing Automatic Case Allocation Forwarding Consolidation DTN Communication Infrastructure Kiosknet Hardware

30 Design Overview GUI Automatic Case DICOM Viewer DCMTK Creator Decomposer Allocation Forwarding Consolidation DTN Communication Infrastructure Kiosknet Hardware

31 Design Overview GUI DB GUI DICOM Viewer DCMTK Creator Decomposer DocDBSync DtnReceiver NetReceiver Sender Sender Receiver Consolidation DTN Communication Infrastructure Kiosknet Hardware

32 Automatic Case Allocation Physician database at proxy Doctor s Name, Specialty, Location, ID, IP, address Case specifies only specialty Based on specialty and availability, allocation done Any allocation algorithm can be implemented now

33 Automatic Case Consolidation Unique Case ID assigned to a case at creation One consolidated file per case ID maintained at the proxy Consolidated file can be retrieved from any location

34 Implementation Details Components Hardware Software Databases Application level routing Screenshots

35 Hardware Components Via Box, 512MB RAM, 40 GB HDD, Ethernet, Wireless PC, Low RAM, No HDD, Ethernet, Wireless Soekris Box, 256MB RAM, 40 GB HDD, Wireless Soekris Box, 256MB RAM, 40 GB HDD, Wireless PC (P4), PC, 512MB RAM, 512MB RAM, 80 GB HDD, 40 GB HDD, Ethernet Ethernet Wireless

36 Software Components Debian OS Apache 2.2, PHP 5.2.6, DICOM Viewer Mricro Debian OS dtnd, dcmtk toolkit, dhcp, nfs Creator, Decomposer (java modules) Debian OS dtnd Debian OS dtnd Debian OS Linux OS dtnd, dcmtk Apache 2.2, toolkit, dhcp, PHP nfs Receiver, Creator, Sender Decomposer (java (java modules) modules)

37 Screenshots

38 Results 1 GB data bidirectional transfer Measured time for link detection and transfer time Time to link detection: Worst case 10 mins Throughput: 1 MBPS

39 Future Work SMS integration Call allocation methods Enable querying Security and privacy Utility based routing

40 Summary Rapidly evolving field Many needs and many solutions Success is not dependant on technology alone

41 Summary

42

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