Semester I 2016-17

Assignment for Attendance in EEL736

TELEMEDICINE

By
Shubham Kumar
2012EE50558

Contents
1. Abstract .. 3
2. Definition..3
3. Introduction.4
4. Technological Advances.6
5. Range of Transmission Media..10
6. Issues in Telemedicine...10
7. Clinical use of Telemedicine.12
8. Impediments to growth of ...12
Telemedicine
9. Human Contribution in Telemedicine..13
10. Telemedicine Research..15
11. Telemedicine in Future...15
12. Conclusion....16
13. References.16

Abstract

Fig: Clinical View of Telemedicine

This paper mainly discusses about a bio medical application called TELEMEDCINE
.Telemedicine is a rapidly developing application of clinical medicine where medical
information is transferred via telephone, the Internet or other networks for the purpose of
consulting, and sometimes remote medical procedures or examinations.
In this
paper author started with definition of Telemedicine. We discussed about modes and problems of
data Transfer in Telemedicine. Author also discussed about clinical uses of Telemedicine .It is
also talked about Issues and Research in Telemedicine along with its future challenges and
human interventions. At last it is also discussed about general government policies and at last
conclusions are made.

Telemedicine Defined
Telemedicine refers to the use of various telecommunications by physicians and medical
institutions that provide health care to their patients through electronic or digital means.

Fig: Interaction During Sessions

Telemedicine may be as simple as two health professionals discussing a case over the
telephone, or as complex as using satellite technology and video-conferencing equipment to
conduct a real-time consultation between medical specialists in two different countries.
Telemedicine generally refers to the use of communications and information technologies for the
delivery of clinical care

Introduction
Telemedicine employs technology that makes it possible for heath care providers to care for their
patients in the patients' homes or in other remote areas. Telemedicine affords caregivers the
ability to collect and transfer medical data, still images, and live audio and video transmissions.
Some of the common methods used are ordinary telephone lines, the Internet, and satellites,
although any means of transmission can be used.
Telemedicine is used in a variety of medical fields; for example, cardiology, radiology,
psychiatry, and oncology. Diagnoses, treatments which include telesurgery, physician and patient
education, and medical administration video conferencing between healthcare providers are all
possible with telemedicine.
Telemedicine is also useful as a communication tool between a general practitioner and a
specialist available at a remote location. Monitoring a patient at home using known devices like
blood pressure monitors and transferring the information to a caregiver is a fast growing
emerging service. These remote monitoring solutions have a focus on

current high morbidity chronic diseases and are mainly deployed for the First World. In
developing countries a new way of practicing telemedicine is emerging better known as Primary
Remote Diagnostic Visits whereby a doctor uses devices to remotely examine and treat a patient.
This new technology and principle of practicing medicine holds big promises to solving major
health care delivery problems in for instance Southern Africa because Primary Remote
Diagnostic Consultations not only monitors an already diagnosed chronic disease, but has the
promise to diagnosing and managing the diseases a patient will typically visit a general
practitioner for.

Telemedicine is currently being used

to bridge the physical distance
between patients in remote areas and
medical specialists around the world.
Developing countries have had little
experience
or
success
with
telemedicine, in part because of the
prohibitively expensive equipment
and connectivity costs involved.
Developing countries require lowcost,
sustainable
telemedicine
solutions for the local delivery of
primary healthcare and efficient
access to medical expertise when
needed.

Telemedicine has advanced significantly in the developed world since then; it is

now used in a wide variety of settings ranging from simple doctor-patient
telephone and email consultations, to sophisticated Virtual Realty (VR) enhanced
telesurgery. It is used in remote areas, correctional institutions, in the military and
in space. The most common use of telemedicine is in areas where there are
shortages of doctors and specialists that can diagnose specific medical
conditions.

For example, the patient in above Figure is getting

an ear examination by a general practice doctor and his
assistant, while a live video stream of her inner
ear is transmitted to a specialist across the country.
Since it is inconvenient for
both the patient and the doctor to travel the distances
required to see each other
in person, videoconferencing technology is used to
bridge the physical distance
that exists between them .

Technological Advances
Advances in several fields of technology and telecommunications help enable the creation of a
multi-diagnostic device such as the TeleCorder described above. In order for a device to be used
in a widespread fashion throughout the world, it needs to be low cost (hundreds, not thousands of
dollars), highly functional, accurate, adaptable to multiple languages and customizable to address
vastly different medical needs. It would literally be a convergence of sensing, computing and
communications and would have artificial intelligence capabilities to complement and enhance
the user.s diagnostic capabilities. The sections below contain brief descriptions of some of the
technologies that will make the creation of a TeleCorder possible in the future.
1 Computing
Moore.s Law predicts that the amount of processing power and memory storage of computers
will double roughly every 18 to 24 months. This means that the computing power and memory
that today is only available in the processors of large personal computers will be available next
year sometime in microchips that are half the size. Personal Digital Assistant (PDA) devices
such as the Palm Computing Palm Pilot. or the Handspring Visor are already capable of tasks
that were simply not possible in such small form factors just a few years ago.
These systems are likely to continue to develop and decrease in cost, offering consumers
access to information and communications anytime, anywhere. In conjunction with the

development of these devices, there have been advances in the peripherals that interface with
them and extend their capabilities..
2 Artificial Intelligence
Expert Systems for clinical decision support are commonplace in many areas of medicine .
Mycin, one of the most famous expert systems, was developed in the mid 1970.s by Edward H.
Shortliffe at Stanford University. It was designed to be an intelligent medical diagnostic tool that
could help identify medical conditions. In 1979, the Journal of American Medical Association
recognized that Mycin was .as good as medical experts.Development in software agents and
intelligent systems has continued since then at an accelerated pace, becoming more powerful as
computing capabilities
have increased.
NASA, for example, has successfully employed modern complex expert systems of this
type in manned missions in order to offer immediate decision-making support to astronauts with
medical emergencies in space.A TeleCorder would require intelligent software that can perform
expedient analysis of large amounts of data, giving immediate results and recommendations to
patients or practitioners regarding their most probable condition based on the collective
experience of many experts and aided by the computational power of the embedded processor
(and any larger databases to which it is wirelessly connected).
3 Data Compression and Transmission
Along with increasing computer power and memory storage has come the ability to compress
images, video and sound more efficiently. Compression is typ expressed as the fraction of
uncompressed to compressed data. While lossless compression can achieve at best a ratio of 2:1,
lossy compression algorithms can achieve ratios that are much higher (up to 10:1, but since it
produces an irreversible loss of information, it needs to be done at a level that does not eliminate
critical medical information) . Major savings are achieved by compressing video, because in
many applications, images change very little from one
frame to the next (primarily the backgrounds and
relatively stationary objects). Further savings can be
achieved within frames by abbreviating the code
required to represent uniformly colored areas ..

4 Wireless Communications
In recent years there has been a trend towards wireless
communications throughout the world. This was first
seen with the extension of cellular systems for
telephony, which have tremendous advantages, especially for providing telecommunications to
areas that have no landline infrastructure. Today, an even greater change is taking place, with
enterprises offering full wireless connectivity not only for communications, but also for access to
multimedia information through the use of web-enabled devices such as PDA.s, cell phones and
twoway pagers..
5 Medical Sensors
The TeleCorder would be capable of non-invasive sensing of multiple types of human
physiological parameters. There have been recent advances in sensing technologies, like the

development of the GlucoWatch Biographer (made by Cygnus, Inc. in Redwood City, CA).
The GlucoWatch is watch-sized blood glucose monitoring system that provides painless and
automatic measurement of blood sugar levels for diabetics.
Also, there has been rapid development in the field of biosensors, which are electronic devices
that convert biologic inputs (such as blood pressure, joint position, or brain waves) into electrical
signals . Biosensors integrated into the TeleCorder and its wireless protocol could allow rapid,
on-site diagnoses of a wide variety of human diseases and medical conditions. Up until recently,
smell has been difficult to digitize accurately, but portable products for doing this are now
starting to appear on the market
6 Medical Records
A TeleCorder needs to be capable of rapidly accessing a wide variety of electronic medical
records (EMRs) for research, education and medical practice. The uses of EMRs are ever
increasing and they have obvious advantages over paper-based records. However, the true
potential of EMRs is currently limited because of the lack of universal standards and because
patients are prevented from accessing and controlling their own records . The future of EMRs is
universal, integrated, patient-controlled records that can be accessed from any point by patients
and selected practitioners when and where they are needed. A useful application involving
medical records would be to have the results of telemedicine consultations throughout the world
tied to a publicly accessible database (all personal information would get stripped out of the
records to maintain patient confidentiality). This database could be an invaluable reference
source for practitioners, doctors, researchers and patients. Answers to commonly asked questions
could be archived along with images, audio and video of common (or uncommon) conditions. 60
or bacterial infections (such as those common to leg or burn wounds23). A sensor of this type in
the TeleCorder could provide practitioners with a tool for performing quick and accurate
diagnoses in remote areas.
.

II Home Health Monitoring

There are a growing number of people with access to the Internet at home and a large percentage
of these people schedule regular visits to see their doctors in person. Many of the visits are
check-ups or follow-ups from previous treatments that could be done more efficiently with a 10minute real-time or store-andforward telemedicine consultation. Traveling to see a doctor
regularly is inconvenient, especially for people with medical conditions in remote areas. A home
solution could reduce the number of
unnecessary physical visits to the hospital, letting
doctors decide when patients should be seen in
person. In order for a home solution to work,
medical devices need to be instrumented to output
their data to a computer with an Internet
connection. An alternative solution could be to IPenable the medical devices themselves by using a
chip such as the Filament. A wireless home
application however, could provide the freedom
and ease of use necessary to make home health

monitoring widespread in developed and developing countries alike.

.

III Wireless Transduction from Medical Devices

A small transceiver board was designed and built in order to demonstrate the capability of
transmitting low bit-rate information wirelessly from various consumer home medical devices to
a central base station (usually a personal computer).

Fig :Wireless transmission Devices

Above figure illustrates this concept with multiple devices.a blood pressure monitor, a scale, a
video camera, a stethoscope, an ECG recorder and thermometer are depicted communicating
wirelessly with a base station computer. This transceiver board (see Figure ) can be embedded
into the devices, making their presence .transparent. to the user. While the patients use the
devices, the base station logs the telemetry to a file and periodically uploads it to a network for
their doctors to review..
For applications like streaming audio from a stethoscope or even images or video from a
camera, a higher bandwidth wireless protocol such as Bluetooth. Would allow seamless
networking between medical devices27. The Bluetooth protocol has built in serial, USB and
audio interfaces, which would make it easy to adapt
This is not the ideal way to capture data, but it works for illustration purposes. Ideally the device
would be manufactured with RS-232 or USB output so that it could communicate seamlessly
with a PC. Bluetooth. is a wireless communications specification intended to provide small form
factor, low-cost, short-range radio links between mobile PCs, mobile phones and other portable
devices.

The Range of Transmission Media

Telemedicine has used various terrestrial and space-based (satellite) transmission media. The
medium that is used is important in part because its bandwidth or bit rate (the amount of
information sent per unit of time) limits the type of technology that may be used. Narrowbandwidth systems, such as ordinary telephone lines, are inexpensive but lack the capacity for
full-motion video. They may be adequate, however, for transmitting still images, voice, text, or
data. No single technology or bandwidth is best for all telemedicine purposes; rather, each
system's capacities and capabilities must be determined by the needs of the users.
Broad-bandwidth networks have transmission rates that permit interactive, full-motion video.
For example, T1 lines have a relatively high bit rate of 1.544 megabits per second. They are not,
however, available in many rural and frontier areas. Interactive video may be used with narrower
bandwidths if data compression algorithms are also used, but the images are sometimes too jerky
to permit resolution of detail or subtle movement. Broad-bandwidth networks are costly because
transmission charges are directly related to bandwidth. This problem was partly addressed by
rules that were developed by the U.S. Federal Communications Commission for the
implementation of changes in the universal service program under the Telecommunications Act
of 1996. These rules provide subsidies for telecommunications services, for which certain rural
health care providers are eligible.

Issues in Telemedicine
1 Quality of the Data Captured
There are cost trade-offs associated with the quality of data that
is captured, stored and transmitted over networks such as the
Internet. Higher quality data usually equates to larger file sizes,
which in turn means longer network transfer times. Choosing
appropriate audio, image and video quality for telemedicine is
important to ensure accurate diagnoses on the part of the
doctors, while keeping network traffic down. Advances in data
compression techniques as well as the rapid growth of
bandwidth available for network communications makes many
of the limitations encountered today become less of an issue in the near future. The effects of
quality on the diagnostics are briefly discussed below for each type of data file.

Fig :Data Transmission

2 Quality of Audio Recordings

The dynamic range of the heart and lungs is 20Hz to 2KHz . In order to preserve sound quality
during recording, sampling should be done at a rate that is at least twice the highest frequency of
interest (2kHz in the case of the heart and lungs). This is known as the Nyquist sampling rate.the
rate at which no aliasing occurs . Of course it is better to sample at a rate higher than 4kHz, for
improved sound quality. As a point of comparison, a 10 second uncompressed (16 bits per
sample) mono audio file sampled at 8kHz produces a file that is approximately 83 kilobytes,
while the same recording at
44.1 kHz takes up approximately 390 kilobytes of memory. Subsequent compression of these
files can reduce their sizes by significant factors

3 Quality of Still Images and Video

Images and video need to have certain quality characteristics in order to be acceptable for remote
diagnostics. The quality required is highly dependant on the application: for example an image
taken to show the general region of a rash on a patients hand can be of very low quality (i.e., 200
x 200 pixels, 8 bits, grayscale intensity resolution) and still serve it.s purpose. Similarly, modern
digital Computed Tomography (CT) scans can be processed so that images that are only 256 x
256 pixels and 8 bit grayscale can be transmitted for effective diagnoses . However, a digitized
chest x-ray for example, needs to be of a much higher quality (2000 x 2000 pixels with a 12 bit
dynamic range) in
order to be useful for remote diagnoses. Researchers at the University of Arizona conducted a
study to evaluate the effectiveness of digital hotography for dermatological diagnoses by
comparing them with in-person visits. They found that there was 83% concordance between inperson visits and the teledermatology diagnoses (using a Cannon PowerShot600 digital camera at
832 x 608 pixels and 24 bit color resolution).

4.3 Medical Approval for Peripheral Devices

A very important aspect of telemedicine is being able to log and transfer data automatically from
the peripheral devices to a computer. When choosing the peripheral devices for the telemedicine
kit, it was found that those that could be purchased with data output ports were significantly
more expensive than similar devices without ports. It appears that the cost difference comes from
the fact that the output-enabled devices fall into a different category than their consumer
gradecounterparts.

Clinical Uses of Telemedicine

Most of the early telemedicine programs used interactive video to bring patients, referring
providers, and consultants together. From 1959 until the 1970s, telemedicine was tested in
medical schools, state psychiatric hospitals, municipal airports, jails, nursing homes, Native
American reservations, and other settings . Most of these early programs proved too costly to be
self-sustaining and were terminated when external funding ran out.
The clinical applications of telemedicine are
even more varied than the technologies, although considerable attention has been focused on the
use of interactive video for specialty and subspecialty consultation in rural areas. The generic

interactive video telemedicine system typically uses fixed, studio-type video equipment to link a
rural facility with an urban tertiary care center. Consultants communicate with patients and,
often, with their primary care providers in an interactive situation.
Almost every
clinical specialty has used telemedicine in some way, although some have used it more than
others. Radiologists, for example, have embraced the technology on a large scale. Cardiologists,
dermatologists, and psychiatrists have been the clinical specialists most actively involved in
telemedicine. The reasons for this are unclear, but this distribution may represent a kind of
"founder's effect" because physicians practicing these specialties were among the clinicians to
first become involved with telemedicine. Nevertheless, the fact that these specialists choose to
see patients through telemedicine suggests that the medium is suited to many of their consultative
tasks.
A
1996 survey of almost 2400 nonfederal rural hospitals [ found that about 17% were participating
in a telemedicine network of some kind (including services as limited as facsimile) and that
another 13% had definite plans to begin using telemedicine. The number of clinics and outpatient
facilities participating in such networks is unknown. Despite widespread interest in telemedicine,
the actual number of patients per telemedicine program who receive telemedicine services
remains relatively low One recent survey of 80 programs (1032 sites on hub-and-spoke
networks) estimated that about 21 000 consultations occurred in 1996 (mean, 37.4 consultations
per site per year) .

Impediments to the Growth of Telemedicine

Lack of reimbursement for telemedicine services is only one of several factors impeding the
expansion of telemedicine . A second difficulty concerns liability and malpractice . Some
providers are concerned that the use of telemedicine may increase their risk (for example, a
technical failure could lead to an adverse patient outcome, or telemedicine could provide an
image of inferior quality that hinders a physician's ability to make an accurate diagnosis).
Conversely, some physicians are concerned that if telemedicine permits high-quality care, they
might be liable for failure to use it. The situation is compounded by interstate variability in the
handling of malpractice claims.
Finally, the issue of
confidentiality remains contentious. The present system of medical records is already insecure,
but there are additional concerns about the ability of electronic medical record systems to
maintain an adequate level of security. In general, electronic records are probably more secure
than paper-based charts, although a possible breach of security may mean that more unauthorized
persons can obtain access to confidential data.
The confidentiality problems that may arise can be classified as breaches
of security and as inappropriate disclosure of individual patient information to persons who are
unauthorized to receive it. Disclosure of information about a specific patient may be as likely
with electronic records as with conventional paper records.
The problem
is being addressed at several levels, both governmental and nongovernmental. Contractual and
legislative protections are needed to provide the highest degree of security that is realistically
attainable. The availability of electronic medical records is of great importance to telemedicine;

as medical information systems evolve, telemedicine may disappear as a distinct entity and be
subsumed into medical information networks. Thus, technological safeguards are also
mandatory.

Human Contribution in Telemedicine

Video-Based Behavior and Communications. The use of video-mediated channels will require
human factors specialists to address issues relating to communicating. Communication and
interpretation over such media can differ greatly from face-to-face conversations. Understanding
the effect on users and information exchange will be critical to telemedicine's acceptance.
Needs Analysis for a Broad Audience. When designing a telemedicine system, it is crucial to
conduct a needs analysis to define the types of users, which will range from medical
professionals to the patients. These audience definitions are critical to design and evaluation
activities. Knowing who the users are and how they intend to use the system is invaluable for
ensuring that the system acts and reacts the way each user expects it to. Another key aspect of
the needs analysis is to understand specifically what users want the system to do. This particular
task analysis will define the nature of the functions and their allocation within the system.
Designing Systems and Components. Human factors specialists apply a user-centered
perspective to designing hardware, software, procedures, and interfaces. This perspective and
process complements those of engineering and programming disciplines by ensuring that the user
rather than the technology remains the focal point of the system. Design considerations range
from the physical (biomechanics, anthropometrics) to the perceptual (audition, vision) to the
cognitive (decision making, memory load, verbal comprehension). For telemedicine to be
successful, usability must be addressed as early as possible in the design.
Choosing among Competing Systems and Components. Benchmarking the usability of a
system is important for evaluating its effectiveness, but competitive usability testing is also a
powerful approach to selecting the best systems and components. Head-to-head tests and
evaluations ensure that usability is given equal weight as functionality at the design stage.
Identifying Good Candidate Applications for Telemedicine. The emergence of certain fields
amenable to telemedicine such as teleradiology, teledermatology, teleoncology, and
telediagnosticshas represented selection based on the existence or development of
technologies supporting that field. Selecting appropriate candidates for telemedicine applications
for the more general user population will not be as straightforward. Human factors specialists
must employ observational and requirements-gathering techniques to assist medical
professionals in identifying and defining candidate activities..
Designing Interfaces for TV Use. It is important that the links and equipment for home-based
systems demonstrate very good usability. Moreover, for most home users, the less computer

based a system is, the better. For this reason, and with the technology on the foreseeable horizon,
the more that telemedical functionality can be channeled through television, the more accessible
and usable it will be. It will be critical to design TV interfaces to provide functionality through
on-screen menus and set-top-box technology.
Designing Home Medical Devices and Protocols. Because capabilities and limitations vary
widely for general users, home-use devices need to be designed to be simple, safe, and extremely
usable. Devices must be designed to be nonthreatening and to inhibit, if not prohibit, incorrect or
unsafe use. Over time, many such devices could enable biodata to be collected by home-care
providers or medical professionals who visit periodically. Device hardware, software,
documentation, and training should be designed for the lowest reasonably defined level of skill
and ability.
Test and Evaluation of Applications and Components. Devices, systems, products,
applications, documentation, and training all need careful scrutiny. Human factors specialists
must test all components of a system to ensure that it meets the intended use provisions of the
FDA regulations. Such systems will require test protocols for data collection and analysis to
ensure the usability and safety of components. They will also require measures and measurement
systems for assessing the usability and efficacy of telemedicine services and functions

Telemedicine Research

Despite the growth of telemedicine, limited research supports the medical effectiveness and costeffectiveness of the technology . Studies conducted in the 1970s showed that the effectiveness of
interactive video telemedicine, audio-only telemedicine, and in-person care were similar ;
although this has been supported by recent research, these three methods of care delivery may not
always be equivalent . Many claims have been made about the cost-effectiveness of telemedicine,
but telemedicine applications must be examined individually. Cost-effectiveness has not yet been
studied for any application, although smaller-scale financial analyses have examined the use of
telemedicine, especially in prisons ].

Telemedicine Future
A critical hurdle must be overcome if telemedicine is to have an impact on the medical industry.
The products and systems, processes, and procedures that make up telemedicine must be usable.
The degree to which telemedicine's components are usable will either inhibit or facilitate its
acceptance, use, and growth and its effectiveness as a model for medical care provision. Poor
usability could at a minimum retard the growth of telemedicine and drastically reduce acceptance
of telemedical technologies.

Poor usability has already had a negative effect on acceptance of these technologies by some
medical professionals. Human factors is a key discipline for addressing interface design, humansystem interaction, user performance, and usability. Moreover, human factors is the primary
discipline for reducing and managing human error and its consequences, particularly for systems
that require decision making and complex cognitive activities.
The rapid technological advances in the fields of computing, artificial intelligence,data
storage and compression and high speed wireless communications coupled with the development
of new non-invasive biological and medical sensors are creating new possibilities for remote
medical sensing in the future.
Also, there is increasing recognition that the home is one of the best places to
deliver healthcare it allows patients to actively participate in maintaining optimum health, while
reducing their need to visit hospitals. In the future, dozens of unobtrusive sensors embedded into
the home could wirelessly transmit medical telemetry to a personal computer and periodically
update a secure database that is controlled by the patient and accessible by their doctors. For
home health monitoring to work in this fashion, the relevant household items need to be
equipped with the technology to sense and transmit physiological parameters seamlessly to a
base station computer.
As a step towards the futuristic home health scenario described above, a small,
low power transceiver board that was designed and built to demonstrate thefeasibility of
inexpensively enabling existing home healthcare devices to communicate wirelessly. This board
was designed in such a way that it could be used in almost any type of low bit-rate medical or
consumer electronic device.

Conclusions
Although there are still issues to address, the need for an alternative operational and business
model for medicine as well as the drive to democratize medicine will accelerate the development
of telemedicine. More importantly, we must recognize that telemedicine systems must be
designed and implemented to include the general population of care providers, patients, and
other users. This means that telemedicine systems, products, tools, functions, and interfaces must
be usable as well as useful. Usability will play a critical role in the acceptance and efficacy of
telemedicine applications. Human factors as a discipline can and will play an important role in
ensuring that the user remains central to the design of a system and that usability is designed into
the system and verified and validated through test and evaluation.
We must also concentrate on improving condition of Telemedicine in developing
countries .Different methods to handle those costs and awareness must be focused in order of
health to reach to nooks and corners of the country.

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