Potential of indigenously developed Telemedicine using Internet

- Local Solutions with Global Potential

Prof K Siddique-e RabbaniDepartment of Biomedical Physics & Technology

University of Dhaka Bangladesh

rabbani@du.ac.bd

www.bmpt.du.ac.bd

Keynote lecture, bdNOG5, 11 April 2016

What is Telemedicine? – medicine at a distance

Through a medium that connects patients in one location to doctors in another location. Doctor provides prescription through the connectivity medium

DoctorPatientHealth

Operator

Telemedicine -History

Soon after its invention Telephone allowed tele-consultation with doctors.

The term ‘Telemedicine’ – coined in 1970s.

Modern ICT has increased the potential of Telemedicine widely

o Telephoneo Radioo Televisiono Mobile Telephoneo Internet

Telemedicine –Iconic picture

Telemedicine – in the West -1 Specialised consultation (even from a hospital)

Telemedicine – in the West -2 Home patient care (for the aged)

o Using mobile unito Auto detection in normal

daily life Detectors in bed,

chairs, toilet seats, clothings

Auto alarm to nearest

healthcare centre

Telemedicine in Low Resource Countries – a different perspective

• About 70% of total population lives in rural areas

• Country average: 3.6 doctors for 10,000 people

• Much much less in rural areas

In the West very few live in villages

Example: Healthcare scenario in rural Bangladesh

1. District Hospitals: 642. Semi-rural (Upazilla) Health Complexes:

400 (Hospitals with X-ray, Pathology and other facilities).

3. 4000 Outpatient facilities with GPs (union based)

4. Rural (Ward) Community Clinics: 11,000 with 3 month trained med assistants, a few have midwifery.

Bangladesh: Govt Infrastructure

Govt finds it very difficult to retain specialist doctors in (1) and GPs at (2). Situation likely to continue for many years – depends on socio economic conditions

Overall status of healthcare in rural Bangladesh• Most rural people consult village doctors or quacks or

pharmacists with little or no formal education or trainingo Leads to maltreatmento Abuse of drugs, antibiotics

• For emergencies – people go to hospitals – expensive, difficult logistics

• Females, children, old, disabled – mostly go without treatment at all.

Solution ? - Telemedicine

Internet

Telemedicine – in the Low Resource countries

FeverHeadacheAbdominal

painDiarrhoeaRespiratory

problemsEye & Ear

problemsEarly heart

problemsEarly

obstetrics & Gynecological problems

Pain at joints Skin problemsEarly DiabetesEtc…..

Primary and Secondary Healthcare- cover majority of medical problems

Telemedicine – in the Low Resource countries

Limitations of Telemedicine: No emergencies, no surgical interventions

Patients need to know if specialised attention or hospitalisation is required or not.

Alternative: Go to a hospital in the town and find out – spending money, time of patient and attendant, logistics, harassment in overloaded hospitals

Opportunity for TelemedicineInternet and mobile phone networks cover almost the whole of Bangladesh. Telemedicine can use both these media effectively.

Mobile phone coverage

Dimensions of Telemedicine Audio Audio + Visual (Video conference) + diagnostic measurements

(Ultrasound scan, ECG, ear, eye images, stethoscope sounds, skin images, etc.)

Live and/or Store & forward

How many rural TM centres do we need in Bangladesh? 4500 unions: population av: 250,000 11000 community clinics: population av: 10,000

At least 4500 telemedicine centres needed ( better 11000)

Considerations: Cost Suitability to our weather and power line Servicing and repair

If foreign equipment used, situation?

Very expensive to procure Fails frequently under our weather and power line conditions Repair unrealistic, cost prohibitive

(purchasing a new one is more cost effective than repairing) Waste of resources

If foreign equipment used, situation?Example:

Donated Medical equipment in low resource countries 70% are not in use – either out of order, or not appropriate Waste initial transfer and installation costs, hospital space

when dumped (cannot throw out, nor can use)(Bill Gentles, University of Toronto, Canada, at World Congress of Medical

Physics & Biomedical Engineering, 2015)

If indigenously developed Lower cost Can be designed to suit local weather and power line

conditions at little extra cost User interface can be designed to suit local language, culture

and practices Repair ensured at low cost (local expertise, availability of

spares) Long usable life (decades) Saving of scarce resources

Desirable for deployment in large numbers

Our efforts at Dhaka university, since 2010Dept of Biomedical Physics & Technology [BMPT-DU] with its background in the dept of Physics

Experience in design & development of IT enabled (computerised) medical equipment since 1986.

1988 2000 2014

Our efforts at Dhaka university, since 2010Dept of Biomedical Physics & Technology [BMPT-DU] with its background in the dept of Physics

Learnt in 2010 - internet with video links in 400 Upazilla Health Complexes

Initiated the effort towards developing a PC based telemedicine system that uses internet.

Why PC?A PC gives a greater capability of data capture. Most rural centres can have PC. Besides we had more experience with a PC.

Telemedicine through rural centres

Internet

‘Dhaka University Telemedicine Programme’ Address: www.telemedbd.net

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Basic Telemedicine Network

CLOUDServer

Initial development of devices for Telemedicine, PC based

• ECG, 12 lead, full diagnostic

• Stethoscope

• Lungs ventilation monitor / Respiration Monitor

• Improvised Microscope

• Multipurpose imaging camera on flexible stand (for

X-Ray film, Skin images, old reports)

• Digital Colposcope (for cervical cancer

investigation)

• Palpation (conceptual innovation - ours)

Basic equipment – commercially available ones- manually typed in results

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Basic Scheme of the System at Rural Telemedicine Centres

Loca

l PC

Digital Stethoscope

Digital Microscope

Digital X-ray viewer

Digital Colposcope

Digital ECG, 12 lead

Sound input jack of PC

USB port of PC

USB port of PC

USB port of PC

USB port of PC

Display

Report generation

Audio system with extra bass sensitivity

Archiving and printing

Typed data entry through PC keyboard

Earphone with extra bass sensitivity

Internet link

Video conferencing link

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Basic Scheme of the System at the Doctor’s end

Loca

l PC

Display

Report generation

Audio system with extra bass sensitivity

Data Base, Archiving and printing

Earphone with extra bass sensitivity

Internet link

Video conferencing link

Typed data entry through PC keyboard

Computerised ECG, our own design Single Channel, 12 lead: for telemedicine, or for stand-alone use

Hand crafted aluminium cabinet Hand crafted Leather bag for Tablet model Compact size

Branded:BANGLAMED

BANGLAMED ECG allows live data transmission through internet

Internet

Combined ECG traces. May be sent to Cardiologist via website or email

Certification for ECG equipmentObtained through DG Health, Bangladesh Govt.

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PC based Stethoscope

Microphone connected to stethoscope head Needs low frequency response for heart & lung

sounds (30Hz to 2kHz) Live transmission of sound desired

Problem: Skype or Google talk do not

provide the low frequency response needed

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Stethoscope – our solution: store & forward

Use ‘Skype’ first. Doctor guides operator to position the stethoscope head properly

Then use ‘Audacity’ to record 5 to 10 seconds of data and save file.

Send file through Skype

Doctor listens to recorded sound, of good quality

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Multipurpose Imaging camera with flexible arm

2 Mpixel camera, Carl Zeiss Glass Lens, software zoom

Possible use:1. Patient’s

appearance2. Dermatology3. Film X-Ray digitiser4. Ultrasound scan

image grabbing5. Written record

digitiser (scanning)

Improvised Digital Microscope

Much cheaper than imported ones.

Good quality camera, 2MPixel, glass lens,

video and sound

Good for teaching schools,

medical college

Rural health centre has technicians, but not

pathologists

Electrical Impedance based (our indigenous design)

Focused Impedance Method (FIM - our innovation)

Localised Lungs Ventilation & Respiration rate monitor

VI

Localised Lungs ventilation & Respiration Rate Monitor using Electrical Impedance

0.0 0.5 1.0 1.5 2.0 2.5 3.00 30 60 90 120 150 180

Frequency, HzRate per min

FFT

Ampl

itude

Time, Sec Am

plitu

de

Challenge: baby should not cry!!

Pneumonia detection in children Needs accurate respiration rate

We innovated a soft palm-worn electrode.Mother wears it and places on child’s thorax.Result - Success ! Babies did not cry!!

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Digital Colposcope for detection of Cervical Cancer

Improvised from a binocular

Digital Image of cervix taken using this Colposcope

Prescription generation

With database for medicines, advices, etc.

Dhaka University Telemedicine Programme

Chronology:2010-12: R&D started, few equipment made

2013: Field trial (through an NGO)

2015: Support by A2I, success of field trial

2015: Permission from DG Health for DU

2015: DU approves use of its name

2015: Grant from ISIF-Asia to develop a mobile phone based system

2016 (April): 9 rural centres running

2016: Monthly patient: 500 (av)

2017: reach out to other countries

Organised by Dept of Biomedical Physics & Technology

Affordable Sustained (repair and maintenance is ensured) User friendly (designed to suit local customs,

culture and psychological traits)

Telemedicine using homegrown technology

If we can install these for all 4500 unions, it will bring a revolution in healthcare in the rural areas.

Dissemination (Field Trial)Challenges:• Technical

(Bandwidth – video conferencing, Ultrasound image streaming)

• Self sustaining model• Doctor/operator – training, quality• Marketing (competing threats)• Monitoring

Rural Healthcare through Telemedicine

Financial Support by

Farm Fresh (initial, in 2011)

Beximco Pharma (2014-16)

A2I (PMO-GOB) (2015)

ISIF-Asia (Australia based) (2015-16)

Sky is the limit

…… Thank You