prof. s k mishra, ms, facs head, dept. of endocrine...

Telemedicine Application in Surgery : Indian Experienceand

Update on Telemedicine Activities in India.

Prof. S K Mishra, MS, FACS

Head, Dept. of Endocrine Surgery

Nodal Officer Telemedicine

SGPGIMS, Lucknow,India

Question 14 1/2: ITU-D Study Groups

Rapporteur’s Group Meeting, Tokyo, Japan, 22 June 2005

Telemedicine

The use of advanced telecommunications

technologies to exchange health information

and provide health care services across

geographic, time, social, and cultural

barriers

Application of Telemedicine in Surgery

• Telesurgery– Telepresence Surgery– Telerobotics– Telementoring / Teleproctoring

• Tele healthcare for surgical patients– Teleconsultation (including intra-operative) – Pre referral screening– Tele follow up– Remote treatment planning

• Distant surgical education – Teleconferencing of surgical conferences, CMEs and Workshops – Web casting – Surgical education portals – Interactive virtual class room

Technical Requirement

• Broadband communication media

• High resolution display devices

• High end video camera

• Video-conferencing equipment

• Highly skilled technologist

• Equipments e.g. Surgical Robotics

Tele-surgery

Surgery, procedure or technique performed on

an inanimate trainer, animate model, or patient

in which the surgeon is not at the immediate

site of the model or patient being operated on.

Visualization and manipulation of the tissues

and equipment is performed using ‘electronic

devices’

Society of AmericanGastrointestinal Endoscopic Surgeons. Guidelines for the surgical practiceof telemedicine. Surg Endosc 2000; 14: 975-979.

Concerns about Telesurgery

• Cost of installing and maintaining a robotic system

• Safety of the procedure • Medico-legal • Licensing and regulation • Complications in Surgery

– Telesurgeon’s mistake– Technical failure

Source: Eadie LH, Seifalian AM, Davidson BR. Telemedicine in Surgery. Br. J. Surg 2003;90:647-658.

Benefits of Telesurgery

• Cost Effective• Expertise from National and International Specialists • Enhance and Extend the skill and range • Three dimensional fashion • Camera position can be controlled automatically

through voice command • Minimized surgical error & enhanced performance of

surgeon• Reducing Fatigue • Precise movements through robotic assistance


Benefits of Telesurgery

The robot can perform very precise surgery

The robot can insert screws into thevertebrae

Surgeon can practice using virtual reality technique

Indian Experience

Robotic Surgery

• Robot assisted cardiac surgery

– All India Institute of Medical Sciences, New

Delhi

– Escort Heart Institute, New Delhi

– CARE Hospital, Hyderabad

• No reported case of tele-robotic surgery

Tele-proctoring

• Mentoring and evaluation of surgical trainees

from distance with the involvement of

broadband connectivity, power cams, and

sophisticated videoconferencing equipment


Tele-proctering:Amrita Institute of Medical Sciences (AIMS), Kochi (January 2003)

• AIMS set up temporary field telemedicine unit to provide public health and emergency care for the pilgrims of Sabarimala shrine

• Connectivity through satellite provided by Indian Space Research Organisation

• A patient with air trapped inside his chest cavity and one of his lung had completely collapsed came with life threatening condition

• Cardiovascular Thoracic surgeon from AIMS guided a cardiologist at field hospital to perform thoracic intervention using telemedicine technology

Stabilized patient after thoracic drainage performed through Telemedicine Technology

Source: http://arl.amrita.edu/telemedicine.html

Tele-mentoring

Real-time interactive teaching of

techniques by an expert surgeon to a

student not at the same site

Tele-mentoring Trial by SGPGIMS

• Between SGPGIMS, Lucknow and AIMS,

Kochi (April’ 2004)

• Primary Hyperparathyroidism

• Broadband telecommunication (ISRO)

•18 yr old boy , presented first in May 2002 at AIMS, Kochi

•Diagnosed as a case of primary hyperparathyroidism

•Operated in May 2002 – Failure (Tumor could not be located)

•Reoperated in July 2002 – Failure (Tumor could not be removed)

•Patient went home , reported after 2 years of Ayurvedictreatment

Case Study

• March 2004 :

Patient readmitted with advanced primary

Hyperparathyroidism with continuous body pains –

crippled, Bedridden with contractures , deformities

& bed sores

Case Study Contd.

Case discussed with SGPGIMS in one of the monthlytelemedicine session

Suggestions from SGPGIMS:a) Tumor has to be located and removedb) Offered assistance during surgery remotelyc) Detail road map of re-operation worked out d) Telementoring schedule fixed

Tele-consultation and Treatment Planning

1) Telemedicine centers at AIMS & SGPGIMS are connected with satellite link for regular telesessions

2) Video camera with cable link was installed in the Operation Theatre at AIMS

3) ISRO Hub was requested to provide 2 Mbps bandwidth during trial and on the day of telementoring

4) Trial teleconference of a live operation in real time from OTwas carried out a day earlier

Materials & Methods

AIMSSGPGIMS

LocalCablenetwork

Video conferencing unit

512 Kbps

512Kbps

Outcome

• The steps of operation was closely watched by the

Mentor

• At a key step the mentor guided the surgeon

• The surgeon followed the advice and located the

tumour which was verified by intra-operative

investigations

• 512 Kbps bandwidth was available

• Telementoring with exchange of good video &audio signals with satellite link is feasible in Indian settingbut more bandwidth needed

• Successful outcome in our case was largely due to the telemedicine technology.

• Difficult cases can now be operated without referralto higher centers with telementoring

Conclusions 1

Conclusion 2• Benefit for surgeon: self confidence boosted and

patient’s confidence regained

• Benefit to patient and Family: Logistics of transport to another hospital avoided, Direct financial and social benefit

• Benefit to hospital: Reputation regained, More complicated patient referred

• Benefit to health care delivery agency / Govt: Quality healthcare through technology intervention thereby people trust on system

• Cost factor & some legal concerns need to be addressed.

Tele-consultation in Surgery

• Evaluation of surgical patient(s), and/or

patient data

• No physical interaction with the patient

• Interaction through telecommunications

interface

Benefits of Tele-consultation in Surgery

• Initial urgent evaluation of patients, triage decisions, and

pretransfer arrangements for patients in an

urgent/emergency situation

• Intra-operative consultations

• Supervision and consultation for primary care

encounters in sites where an equivalently qualified

physician/surgeon is not available

• Routine consultations and second opinions based on

history, physical findings, and available test data

Tele-consultation in Surgery from SGPGIMS

(No. of Cases in each discipline)

44

26

25

3Endosurgery

Urology

Neurosurgery

Gastrosurgery

Teleconsultation in Surgery from SGPGIMS Sept 2001 – April 2005

Tele-follow up in Surgery

Tele-follow up in Endocrine Surgery with Medical Colleges of Orissa State

Distance – 1500km

Tele-follow-up in Endocrine Surgery(March 2004 – April2005)

• Total number of patients : 34

• Males: Females : 1:2

• Age group : 14 to 67yrs

• Total no of visits/patient : 1 to 4 visits

65

35

13

9

0

10

20

30

40

50

60

70

Endo. Surgery Neurosurgery Gastro surgery Urology

No of Session

Specialty wise Telemedicine Sessions

(between SGPGIMS and Medical Colleges of Orissa)Sept’01 to April ’05

(Tele-consultation, Tele-follow-up, Tele-education)

Tele conferencing in Surgery

• Discussion and interaction between surgeons

in a virtual class room environment

• Live surgery demonstration

Source: Society of AmericanGastrointestinal Endoscopic Surgeons. Guidelines for the surgical practiceof telemedicine. Surg Endosc 2000; 14: 975-979.

Different kinds of teleconferencing modalities

• Interactive two way

• One way broadcast

• Web casting

Tele-conferencing in Surgery at SGPGIMS

1st Telesurgical Conference (1999)

• Live Surgery –

Cochin

• High Bandwidth (384

kbps) ISDN

• Interactive Live

Session

1st Telesurgical Conference

Skill Development

2nd Telesurgical Conference (2001)

• Entire Proceedings - SCB

Medical College, Cuttack

• Case Discussion - seven and

half hours

• Guest Lectures - six hours

• Endocrine Imaging – four

hours

• Live Surgery - fifteen hours

• 384kbps bandwidth ISDN

3rd Telesurgical Conference (2003)

• Entire Proceedings - SCB

Medical College, Cuttack

• Surgical Procedure -

Bangalore and Chennai

• Interactive Question Answer

Sessions

• 384kbps bandwidth VSAT

3rd Tele-surgical Conference

1st SGPGI, Breast Course – March 2005, SGPGIMS

• Entire Proceedings -

SCB Medical College,

Cuttack, Orissa,

AIMS,Kochi (Multipoint

connectivity)

• Interactive Question

Answer Sessions

• 3 ISDN Lines – 128

kbps

1st, SGPGI Breast Course

Tele-surgical Sessions in Virtual Classroom Environment

• Distance – 2500 km• Starting Date – March’ 04 – April’05• Total no of sessions In Endocrine Surgery & Surgical

Gastroenterology - 11

First World Summit on Kidney Surgery (February-2003) – AIMS, Kochi

• Urologists in many states in South India • Interactive participation • Live surgery workshop transmitted from

Cleveland, USA to over 12 countries worldwide

• Enabled Radiologists from AIMS to participate in the judge panel for radiology thesis presentations at SRMC, Chennai

Source:http://www.aimshospital.org/telemed.html

Telemedicine Activities in IndiaAn Update

SN -MobileKarnataka• Chamarajanagar• Saragur

Karnataka• Chamarajanagar• Saragur

Orrisa• Cuttak• Burla• Berhampur


Andhra Pradesh• Aragonda• SHAR, Sriharikota


J& K• Srinagar-1• Srinagar-2• Jammu• Katua• Leh

J& K• Srinagar-1• Srinagar-2• Jammu• Katua• Leh

Lakshadweep• Kavaratti• Minicoy• Androttii• Ameni• Agatti


Kerala• Pampa• Pattanamthitta

Kerala• Pampa• Pattanamthitta

Andaman & Nicober• Port Blair• Car Nicobar


36 Nodes • 11 Super Specialty Hospitals• 25 Dist/ Rural Hosapitals

36 Nodes • 11 Super Specialty Hospitals• 25 Dist/ Rural Hosapitals

North East• Udaipur• Gangtok• Guwahati

North East• Udaipur• Gangtok• Guwahati

AMBULANCE

AIIMS,New Delhi

Apollo, New Delhi

NH, Bangaloare

SN, Bangalore

AIMS, Kochi MC,

Trivandrum

Apollo, Chennai

SRMC, Chennai

SGPGMI, Lucknow AHF,

Kolkota

SN, Chennai

ISRO’s TELEMEDICINE NETWORK - ESTABLISHED SO FAR (October 30, 2003)

> 12,000 patients treated

ShanlkaraNetralaya -

Mobile

Karnataka• Chamarajanagar• Saragur•Maddur.•Sagar.•Chitradurga•Karwar•Bagalkot.•Mandya.•Tumkur.•Sirsi

Karnataka• Chamarajanagar• Saragur•Maddur.•Sagar.•Chitradurga•Karwar•Bagalkot.•Mandya.•Tumkur.•Sirsi





J& K• Srinagar-GMC• Srinagar- SKIMS• Jammu• Katua• Leh• Kargil• Kupwara• Doda• Poonch

J& K• Srinagar-GMC• Srinagar- SKIMS• Jammu• Katua• Leh• Kargil• Kupwara• Doda• Poonch



Kerala• Pampa• Pattanamthitta• Kannur

Kerala• Pampa• Pattanamthitta• Kannur



113 Hospitals.--- 87 Dist/ Rural Hospitals,-- 26 Super Specialty Hospitals113 Hospitals.--- 87 Dist/ Rural Hospitals,-- 26 Super Specialty Hospitals

North East• Udaipur(TP)•Guwahati(AS)• Imphal-1(MP)•Jorhat.(AS)•Shillong(MG)•Mokokchung(NL)•Naharlangun(ap)• Gangtok(SK)

North East• Udaipur(TP)•Guwahati(AS)• Imphal-1(MP)•Jorhat.(AS)•Shillong(MG)•Mokokchung(NL)•Naharlangun(ap)• Gangtok(SK)

AMBULANCE

AIIMS,New Delhi

Apollo, New Delhi

NH, Bangaloare SN,

BangaloreAIMS, Kochi

MC, Trivandrum

Apollo, Chennai

SRMC, Chennai

SGPGMI, Lucknow

SN, Chennai

SSKM Kolkata

ISRO’s TELEMEDICINE NETWORK - ESTABLISHED SO FAR

> 20,000 patients treated

R& R,New Delhi

ARMY• Srinagar• Siachin• Leh• Kargiil• Udhampur

ARMY• Srinagar• Siachin• Leh• Kargiil• Udhampur

RCC, Trivandrum

Chhattisgarh• Jagadalpur• Raipur•Marwahi

Chhattisgarh• Jagadalpur• Raipur•Marwahi

West Bengal• Krishnanagar•Malda

West Bengal• Krishnanagar•Malda

AHF, Kolkata

Arvind Eye Hospital

TMC Mumbai

Kerala Oancer net• Cancer center KannurKerala Oancer net• Cancer center Kannur

• B.Barua CC Guwahati.

•Walwaker CC,Chiplun

• B.Barua CC Guwahati.

•Walwaker CC,Chiplun

AMBULANCE

Arvind Eye Hospitalmobile

ISRO Projects under Development

• Development of revenue model of Telemedicine in

public-private partnership model (Philips, Apollo &

ISRO)

• All India Medical College Network in partnership with

IT, Health Ministry & Medical Universities

• Deployment of Village Resource Center

Department of Information Technology (DIT), Govt. of India

• Developed document on Telemedicine

standardization

• Developed document on IT infrastructure for

health

• Funding of R&D projects for health IT

• Setup 45 Telemedicine nodes

DITInitiatives

• Development of telemedicine software & application (C-DAC,AIIMS,SGPGIMS & PGIMER)

• Development of Telemedicine module for Tropical Medicine in West Bengal - Webel (Kolkata), IIT,Kharagpur and School of Tropical Medicine, Kolkata

• Development of Tele-oncology Network - Kerala and Tamilnadu States

• Development of state wide Telemedicine network based on terrestrial communication in the state of Himachal Pradesh

Medical Institution undertaking major Tele-medicine activities

Telemedicine at SGPGIMS,Lucknow

• Telemedicine application project

• Consultancy, project planning and implementation of Telemedicine network in 3 states of Orissa, Uttaranchal, Uttar Pradesh and states of north east of India

• Tele-Consultation & Distant Education in Medicine

• Tele-mentoring

• Research and Product development in Tele- Health in collaboration with Industry

• Human Resource development in Tele-Health

Telemedicine at SGPGIMS,Lucknow Contd..

• Organisational activities in Telemedicine

• Telemedicine awareness activities for

healthcare providers and other stake holders

• National & International collaboration in

technical knowledge exchange & HRD

Human Resource Development & Capacity Building

Initiatives

• Telemedicine• Hospital information system• Medical Image Management and Multimedia• Development of multimedia medical

education Content and Distant Education• Artificial Intelligence• Bio-informatics• Virtual reality in Medicine• Medical robotics

School of Telemedicine & e Health, SGPGIMSCurrent Status

HUBHUBHUB

MEERUT

AGRA

ALIGARH

KANPUR

KGMU,LUCKNOW

ALLAHABAD

VARANASISGPGIMSSGPGIMSLUCKNOWLUCKNOW

UP TELERADIOTHERAPY NETWORK:Department of Science & TechnologyUP TELERADIOTHERAPY NETWORK:Department of Science & Technology

Radiotherapy Network at SGPGIMS

Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh

• To provide modern health facilities at affordable prices in remote areas PGIMER, linked with– Mata Kaushalya Hospital at Patiala– Sub-divisional government hospitals at

Dasuya and Ajnala in Hoshiarpur and Amritsar in Punjab state

Source:http://www.hindu.com/2005/04/14/stories/2005041405310500.htm

The Amrita Institute of Medical Sciences (AIMS), Kochi

• To extend specialty medical care to patients at remote locations• To provide follow-up of post-surgical patients, avoiding needless

travel on their part • To strengthen the skills and confidence of doctors at remote

primary centers and help them build a better relationship with their patients.

• To provide Continuing Medical Education to the Doctors at the peripheral centers and other general hospitals with the latest advancement in the field of Medicine

• To promote Interactive Medical Education between thespeciality medical centers

• To develop low-cost telemedicine software, medical equipments like Patient Monitors for remote management of the patient at the Specialty Centre.


AIMS, KochiEstablished Connectivity

• 36 Telemedicine Centers all over India • Emergency Medical Center at Pampa • Other Tertiary Level Hospitals

– Sree Ramachandra Medical College, Chennai, – Sankara Netralaya, Chennai, – Sanjay Gandhi Post Graduate Institute of Medical Sciences,

Lucknow, – Guwahati Medical College, Assam, – Sher-E-Kashmir Institute of Medical Sciences, J & K, – AIIMS, New Delhi, – Trivandram Medical College, Narayana Hrudayalaya,

Bangalore


Apollo Telemedicine Network FoundationInitiatives

• Corporate Group of Hospitals having branches in India and Abroad

• Networked all its hospitals and use in-house software• Telemedicine consultancy and software providers• Active participants in the Standardization and ITIH activity• Installed a number of peripheral telemedicine nodes

through franchise under Apollo Health Street Company • One of the major player in telemedicine in private sector

Apollo Telemedicine Network Foundation

• Set up over 75 Telemedicine Centres across different

locations in the country and abroad

• Set up a Rural Telemedicine Centre in the village of

Aragonda in the state of Andhra Pradesh which

serves 24 villages covering 48,000 people in the

vicinity and provides access to super-specialists at

the Apollo hospitals in Chennai

Source:http://www.whoindia.org/EIP/GATS/13-Annex2.pdf

http://medind.nic.in/maa/t05/i1/maat05i1p51.pdf

Asia Heart FoundationInitiative

• One of the major private player in telemedicine service provider

• Network number of hospitals in India and Abroad• Most of the service related to cardiac care• Southern Grid operates through Narayana

Hrudayalaya, Bangalore • Eastern Grid operates through R N Tagore

Hospital, Kolkota

Telemedicine by Narayana Hrudayalaya, Bangalore

• Tele-cardiology network in the state of Karnataka, West

Bengal and North East State

• Tele-monitoring of distantly located coronary care unit

• 39 telemedicine centers

• More than 16,4000 Tele-cardiology consultation in India,

Malaysia, Mauritius and Pakistan completed

Shankara NethralayaMobile Tele-ophthalmology Unit

(Real time and Store and Forward)

• Telemedicine Software and Hardware

• 29 inch flat Television

• Ophthalmology Equipments

• Video Slit lamp

• Digital Fundus Camera

• Video Indirect Ophthalmoloscope

• Tonometry

• Connectivity

• VSAT - 384 Kbps

• Laptop with Project and Screen

• Portable wireless amplifier with cordless mike

• Digital Camera

• VHS recorder

Shankara NethralayaTele-ophthalmology ( Statistics upto – March 2005)

7,393Door to Door Enumeration

14,791Awareness meeting attended

250Bangalore Teleconsultation

819Spectacles given 5,852No. of Teleconsultations15,043No. of patients examined

315No. of Camps

TotalParticulars

Total No. of patients benefited so far due to Teleophthalmology : 21,145

Aravind Eyecare Hospital(Tele-ophthalmology)

• Tertiary care on wheels• Centers at Madurai, Theni, Tirunelveli &

Coimbatore districts of South India

Source:http://www.aravind.org/telemedicine/atnnet.htm#

Aravind Eyecare System

Escort Heart Institute Initiatives

• Escort Heart Institute &Research Center, New Delhi

• Networked all its hospitals, mostly in Northern India

• One of the major player in private sector

• Only delivers tele-cardiology service

Tata Memorial Hospital

• Started Tele-pathology service linking with Rural Cancer Hospital at Barshi in 2002

• Tele-oncology service for

– Dr B Borooah Cancer Institute, Guwahati

– Dr Walawalkar Hospital at Dervan, Chiplun

• Networking of six hospitals in the North-East and Regional Cancer Centres to enable patients to access comprehensive cancer care

Source:www.tatamemorialcentre.com

Media Lab Asia InitiativeEmpowering Rural India

Source:www.medialabasia.org.in

Indian institute of Technology, KanpurProject1 – Sehat Sathi

Development of Portable Mobile Rural Healthcare Module

• Software package (Sehat Sathi)– Medical data acquisition – ECG, Eye images, heart &

lung sounds etc)– Interaction between doctor and patient– Rural patient health database management– Content on health & disease:towards health promotion

(www.bimarijankari.org, www.sehatnama.org)

• Source:www.medialabasia.org.in

www.iitk.ac.in

Indian institute of Technology, KharagpurProject2 – Sanyog

• Augmentative Communication System for the speech impaired & people affected with cerebral palsy

• Sanyog System– Natural Language Sentence Generator– Icon Interpretation& Disambiguation– Text to speech system– A predictive virtual key board – Facility to store & retrieve frequently used

messages– Varied access switches

• Languages support – Bengali, Hindi & English• Tested in the field of West Bengal


www.iitkgp.ac.in

Indian institute of Technology, KharagpurProject3 – Shruti

• An Embedded Indian Language Text to Speech System

• Accepts text inputs in two Indian languages – Hindi & Bengali

• Text enter in ITRANS using Roman Characters• Provides a speech based communication interface

for speech impairments& forms an integral part of a talking web browser for visually challenged


www.iitkgp.ac.in

All India Institute of Medical Sciences, New Delhi Project 4 – Ca:Sh

• A replicable model for IT based health system at grass root level

• Developed handheld device for health data collection• Computerised data is maintained at PHCs & CHCs• Data at PHCs & CHCs is digitally updated from the

data on handheld devices• Enables automated generation of work plan on

handhelds• Management of childhood diseases and other

applications

Indian institute of Technology, KanpurProject5 – Infothela

• Designed to accommodate diagnostic equipments like– blood pressure testing machine– blood sugar testing machine– other primary health diagnostic and testing equipments.


www.iitk.ac.in

Indian institute of Technology, DelhiProject 6– Zero Configuration wireless mesh

network

• All wireless network – a mesh of access points

(802.11b)

• Deployment requires no manual configuration

• Readily deployed while offering connectivity and

mobility to any network-ready mobile device

• Used for disaster mitigation & management, sensor

networks & applications requires automatic

configurability

Indian institute of Technology, DelhiProject 6– Zero Configuration wireless mesh

network

Byrraju FoundationProject Ashwini

• 32 Ashwini centers – services offered by these Ashwini centers will be accessed by these and 84 neighboring villages of Andhra Pradesh, South India

• Covering a total population of over 500,000

• Online consultation with specialists to complement the Primary Healthcare efforts

• Broad spectrum coverage – Gynecology, Diabetes, Hypertension, Eyecare, Pediatrics, Epilepsy, Health Education & Promotion

• Continuous Medical Education

Project AshwiniNetworking of 84 villages of Andhra Pradesh

Source:www.Ashwinibyrrajufoundation.org

Indian Conference on Medical Informatics & Telemedicine (ICMIT 2005)

Feb-March 2005, Kharagpur

International Conference on Telemedicine by

Indian Space Research Organisation (ISRO)

[email protected]

Thank Youwww.sgpgitelemedicine.in

prof. s k mishra, ms, facs head, dept. of endocrine...

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