National Rural Telemedicine Network

Suggested Architecture and Guidelines

Draft Proposal Version 1.0

Ministry of Health & Family Welfare

Government of India

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Content

1. Executive Summary.................................................................................................3
2. Introduction..............................................................................................................3
3. Background..............................................................................................................3
4. Current Scenario.......................................................................................................4
5. Scope of the Project.................................................................................................6
6. Expected Benefits.....................................................................................................6
7. Proposed Guidelines / Framework for Indian Rural Telemedicine Network...........7
7.1. Defining a National Rural Telemedicine Network.............................................7
7.2. Standardization First Step Towards National Rural Telemedicine Network....8
7.3. Constituents of Telemedicine Network..............................................................8
7.3.1. LEVEL-1: Primary Health Center (PHC) / Community Health Center
(CHC) / Village Unit................................................................................................8
7.3.2. LEVEL-2: District Hospital.........................................................................8
7.3.3. LEVEL-3: State Hospital / National Super Specialty Hospital....................9
7.3.4. LEVEL-M: Mobile Telemedicine Unit *.....................................................9
7.3.5. NRHM Smart Card....................................................................................10
7.4. Process and Infrastructure Guidelines at Different Layers of Hierarchy.........10
7.4.1. Telemedicine Process for LEVEL-M and LEVEL-1 units........................10
7.4.2. Telemedicine Process for LEVEL-2 and LEVEL-3 units..........................11
7.4.3. Telemedicine Hardware / Software Requirement at LEVEL-M and
LEVEL-1................................................................................................................12
7.4.4. Telemedicine Hardware / Software Requirement at LEVEL-2.................13
7.4.5. Telemedicine Hardware / Software Requirement at LEVEL-3.................14
7.5. Proposed Organizational Plan..........................................................................16
7.5.1. Preparation of Infrastructure, E-Health Education and Training...............16
7.5.2. Setting Guidelines for Administration and Clinical, Educational and
Governance Telemedicine Practices.......................................................................16
7.5.3. Identification of Vendor for Project Implementation.................................16
7.5.4. Recruitment of Technical / Medical Manpower.........................................17
7.5.5. Installation of Equipments, Network Media, Testing, Training and Hand-
Holding...................................................................................................................17
7.5.6. Periodic Monitoring and Preparation of Interim Report............................17
7.5.7. Impact Evaluation at the End of Each Year and After Five Year...............17
8. Budget requirement................................................................................................18
8.1. Financial Requirement for Phase-I...................................................................18
8.2. LEVEL-1 (PHC / CHC / Village) Units...........................................................18
8.3. LEVEL-M (Mobile Telemedicine Van)...........................................................20
8.4. LEVEL-2 (District Hospitals)..........................................................................22
8.5. LEVEL-3 (State Hospital /Super Specialist Hospitals)....................................24
8.6. Financial Summary..........................................................................................26

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1. EXECUTIVE SUMMARY

2. INTRODUCTION

India is the second most populous country of the world and has changing socio-
political-demographic and morbidity patterns that have been drawing global attention
in recent years. Despite several growth-orientated policies adopted by the
government, the widening economic, regional and gender disparities are posing
challenges for the health sector. About 75% of health infrastructure, medical man
power and other health resources are concentrated in urban areas where 27% of the
populations live. Contagious, infectious and waterborne diseases such as diarrhea,
amoebiasis, typhoid, infectious hepatitis, worm infestations, measles, malaria,
tuberculosis, whooping cough, respiratory infections, pneumonia and reproductive
tract infections dominate the morbidity pattern, especially in rural areas. However,
non-communicable diseases such as cancer, blindness, mental illness, hypertension,
cardio vascular disorders, diabetes, HIV/AIDS, accidents and injuries are also on the
rise. The health status of Indians, is still a cause for grave concern, especially that of
the rural population. This is reflected in the life expectancy (63 years), infant
mortality rate (80/1000 live births), maternal mortality rate (438/100 000 live births);
however, over a period some progress has been made. To improve the prevailing
situation, the problem of rural health is to be addressed at both macro (national and
state) and micro (district and regional) levels. This is to be done in a holistic way, with
a genuine effort to bring the poorest of the population to the centre of the fiscal
policies. A paradigm shift from the current 'biomedical model' to a 'socio-cultural
model', which should bridge the gaps and improve quality of rural life, is the current
need. A revised National Health Policy addressing the prevailing inequalities, and
working towards promoting a long-term perspective plan, mainly for rural health, is
imperative. Recent launch of National Rural Health Mission (NHRM) by the Ministry
of Health & Family Welfare is a step in this direction.

3. BACKGROUND

India lives in its villages, so said Mahatma Gandhi, Father of the Nation, but the
country today, after 60 years of independence, is characterized by low penetration of
healthcare services to its village population. Even though there have been several
initiatives taken by both the Government and the Private sector, the rural and remote
areas continue to suffer from absence of quality healthcare services. The health
indicators of the nation are in dismal situation even after implementation of several
nationwide projects to improve it. Recently, the union government has adopted a
mission approach to boost the public health for the masses by launching National
Rural Health Mission (NRHM). One of the objectives of the NRHM is to provide the
rural population access to healthcare services. In this context, Telemedicine, an
information and communication technology based tool, has the potential to assist in

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electronic delivery of diagnostic and healthcare services to remote rural population
even in the absence of physical infrastructure in place thus can create a platform to
network India. Telemedicine helps to provide healthcare where there is none and
improve healthcare where there is some.

The fact is that while 70% of our population lives in rural India; 90% of secondary &
tertiary care facilities are in the cities and towns far away from the rural India. At the
same time, it is also a fact that a significant proportion of patients in these remote
locations could be successfully managed with some advice and guidance from
specialists and super-specialists in the cities and towns. This is the power of
Telemedicine. It is no surprise that Telemedicine is playing an increasingly important
role in not only providing diagnostic and consultation services but also in facilitating
Tele-education and training of personnel across the country.

4. CURRENT SCENARIO

A number of initiatives are underway in the area of telemedicine with the objective for
providing quality consultation and caring for patients in areas where specialized
patient care is not available. Although telemedicine implementation remains in its
infancy, interest and activity appears to be growing to provide consultation of a Super-
specialty doctor from a distance through videoconferencing along with exchange of
medical records online. In addition to major support and thrust provided by DIT
through projects and systems, organizations like ISRO, reputed academic medical
institutions like SGPGI, AIIMS, PGIMER, AIMS, SRMC and corporate hospitals like
Asia Heart Foundation, Apollo Hospitals, SGRH, Fortis, Max etc. have taken and
continuing to take significant initiatives for installation of telemedicine systems at
different parts of the country.

The Department of Information Technology (under MCIT) has taken a pivotal role in
defining and shaping the future of Telemedicine application in India. Backed by a
strong vision to build a national Telemedicine Network in India, DIT has been
involved at multiple levels this includes Development of Technology, Initiation of
pilot schemes and standardization of Telemedicine in the country. Some of these are
briefly described below.

DIT has funded development of Telemedicine software systems- the prominent ones
being Mercury and Sanjeevani software by C-DAC. DIT has also sponsored the
telemedicine project connecting three premier medical institutions- viz. SGPGI,
Lucknow, AIIMS, New Delhi, and PGIMER, Chandigarh- using ISDN connectivity.
These hospitals as in turn connected to other state level hospitals.

DIT Implemented Tele-medicine foe Diagnosis & Monitoring of tropical diseases in

West Bengal using low speed WAN, developed by Webel (Kolkata), IIT, Kharagpur
and School of Tropical Medicine, Kolkata. The system has been installed in School of
Tropical Medicine Kolkata and two District Hospitals.

Similarly, DIT has funded establishment of an Oncology Network for providing

Telemedicine services in cancer detection, treatment, pain relief, patient follow-up and
continuity of care in peripheral hospitals (nodal centers) of RCC. The project was
implemented by C-DAC, Trivandrum and Regional Cancer Center (RCC),
Trivandrum. The Kerala OncoNET model has been replicated by DIT at RCC, Adiyar

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in Chennai with C-DACs Mercury Telemedicine Solution. Success of the cancer
network in Kerala has been adopted by the Ministry of Health & Family Welfare,
Government of India to take major step towards launching National Cancer Care
Network.

Also projects on setting up of telemedicine facilities at two referral hospitals and four
District hospitals using West Bengal State Wide area network of 2 Mbps, and setting
up Telemedicine and Tele-education (continuing Medical Education ) facilities in
Kerala connecting Regional Cancer Center (RCC), Sri Chitra Thirunal Institute of
Medical Sciences(SCTIMST), Medical College Hospital (MCH) and Trivandrum
Medical College (TMC). Trivandrum with four hospitals at Taluk and District level
using ISDN connectivity is implemented with C-DACs Mercury Telemedicine
Solution.

Several state level Telemedicine network like Kerala state Telemedicine Network,
Tamilnadu state Telemedicine Network, Haryana & Panjab state Telemedicine
Network, etc. are coming up as pilot project and have shown promising results.

In addition, three state capital district level hospitals in north eastern states of India
are getting connected with super- specialty hospitals, one at Kohima, Nagaland
already being operational. Another one linking one each state level hospital in Sikkim
and Mizoram with Indraprastha Apollo Hospital is example of Public-Private
Telemedicine Network in place and under effective use.

In a short span of time, some significant progress has been achieved in the field of
Telemedicine in India. However, there is still a long way to go. While there are over
20,000 PHCs providing primary care services in the rural areas, and about 500
district hospitals, Telemedicine has reached to about 100 centers and more 50% of
them are in the urban centers only.

If we were to look at a five- year horizon for Telemedicine in India, efforts would be
considered successful only if we have Telemedicine reaching out to at least all district
and Taluk level hospitals throughout the country. But for this to be a reality, we need a
major thrust not from the Government and Private Sector but also help from
International agencies, which will go a long way in achieving this objective.

One of the key factors to success of Telemedicine in India is going to be the reliability
of telecommunication link. In this context, it is of considerable significance the
commitment made by ISRO Chairman to provide free bandwidth for the purpose of
Telemedicine and Tele-education. ISRO has been deploying satellite based
telemedicine nodes in collaboration with state governments. So far it has deployed
around 250 nodes across the country.

Ministry of Health and Family Welfare has set up a National Task Force to address
various issues to promote telemedicine in the country and has launched a major
country wide network of district hospitals and medical colleges under the Integrated
Disease Surveillance Project. National Cancer Care Network and Medical Colleges
network are going to be implemented in the near future.

In view of a number of laudable but disparate efforts and initiatives, need for an over
arching architecture/ framework for the country covering 3 levels, namely, PHC to
District, District to referral/ Super-specialty hospitals and also covering

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hardware/software requirements, bandwidth and connectivity issues has been felt.
This paves the way for introduction of integrated telemedicine network in India.

Fiber optic network across the country has been laid down by both government /
public sector and private telecommunication service providers paving the way for
availability of high bandwidth terrestrial connectivity to build ubiquitous health
network for telemedicine country wide with competing price. What started as
application of science and technology in the field of telemedicine by the Ministry, it
has now got a significant attention as an important national programme

5. SCOPE OF THE PROJECT

Design, development and implementation of low cost rural telemedicine

infrastructure consisting of fixed, mobile and hand-held platforms and web
technology based broad band wired / wireless wide area network centering around
the district hospital acting as hub.

Design and development of Village Tele-ambulance System and rural emergency

healthcare services / Trauma care module, a new concept, through mobile
telemedicine network based on Wi-MAX wireless mesh network

Development of Rural Health Knowledge Resource through web portal on public

health domain and creation of e-CME module for its access by the stake holders
through e-learning technology on the telemedicine platform

Development of technology platform for harvest, compilation, storage (Data Base)

at regional district hub and central Data Center at MOH & FW, archive and
distribution across network.

6. EXPECTED BENEFITS

Timely access to diagnostic, specialty healthcare advice at the grass root level
through the low cost telemedicine network centering around the district hospital as
the service provider

Augmented rural healthcare delivery system by integration of low cost,

sustainable, scalable fixed, mobile and hand-held telemedicine technology
platform into existing rural healthcare services infrastructure

Creation of a model for Rural Emergency / Trauma services on Telemedicine

infrastructure

Improvement on knowledge base of the rural population (to empower the rural
folks on self healthcare disease prevention & health promotion)

Remote education, training / retraining and skill development of grass root

healthcare workers and professionals under NRHM

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 Ensuring public health related data (as has been incorporated under NRHM)
harvest , compilation, storage at district hub, archive and distribution across
network to facilitate electronic governance of NRHM.

7. PROPOSED GUIDELINES / FRAMEWORK FOR INDIAN RURAL

TELEMEDICINE NETWORK

7.1. Defining a National Rural Telemedicine Network

While ISRO is providing free bandwidth through V SAT connectivity, we are also
looking forward to defining a modal for a National Telemedicine connectivity GRID
on hybrid model utilizing existing terrestrial fiber optic and upcoming wireless media
technology. This would look at utilizing bandwidth across different communication
links depending on the application and the investment considerations. The specific
structure of any particular telemedicine center of the network would depend on the
geographic factors of the area that will be serviced by the network, and the type of
local users there. We visualize the National Rural Telemedicine Network to be a tiered
hierarchical structure. This would include:

LEVEL-1: Primary Health Center (PHC) / Community Health Center (CHC)

connected to a District Hospital
LEVEL-2: District Hospital connected to a State Hospital / National Super
Specialty Hospital
LEVEL-3: State Hospital / National Super Specialty Hospital connected to
each other
LEVEL-M: Mobile Telemedicine Unit covering few villages connected to
nearest PHC / CHC or directly to District Hospital

With special reference to NRHM the PHCs can be scaled down to village level units
up to Village health worker in the proposed network

The LEVEL-1 units are referring in nature and will connect to a pre-designated
LEVEL-2 unit that is referral in nature. It is possible that LEVEL-2 unit may also act
as a referring unit and refer to LEVEL-3 unit. In such a case, LEVEL-2 unit will also
require some medical equipment. LEVEL-3 units are purely referral in nature and will
be able to consult with each other or refer a case to each other on basis of specialty
and requirement of second / third / nth opinion.

In defining the National Rural Telemedicine Network, selecting the connectivity will
be defining factor in reaching out to distant locations including where traditional land
based communication systems have not yet reached or are plagued by poor
connectivity.

This network needs to be based on open platform and on open architecture standards
that make it accessible to one and all. It would not be restrictive in any way and any
party interested to contribute to or benefit from this noble application would be able to
do so. Developing an adequate and affordable telemedicine infrastructure can help to
close the gap between the haves and the have-nots in health care.

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7.2. Standardization First Step Towards National Rural Telemedicine Network

As a starting point of building the National Rural Telemedicine Network, MoH&FW

has initiated defining the national standards and guidelines for Telemedicine
application in India, in consultation with DIT, MCIT. Telemedicine working group
setup has already finalized a nucleus framework Recommendation on Guidelines,
Standards and Practices for Telemedicine in India. Defining standards now will
insure that all our systems are interoperable and are able to communicate with each
other instead of being restrictive and limited to a particular provider network. What
this means is that if a center has a Telemedicine system already implemented, it can
talk to another center with different Telemedicine System as long as they adhere to the
defined standards. This will also form the basis of collaborations - between the
government and private players as well as between different private players with the
patients being the final beneficiaries.

7.3. Constituents of Telemedicine Network

A telemedicine network incorporates following components in addition to Consulting

Doctors and Super Specialty Consultants at both recipient and referral hospitals:

7.3.1. LEVEL-1: Primary Health Center (PHC) / Community Health Center

(CHC) / Village Unit

Tele-consultation room
Patient engagement facilities (bed, scopes, etc.)
Telemedicine Platform
o Selective medical and medico-IT equipments, preferably IT compatible,
with interface to Telemedicine and/or other software / hardware
o Computer hardware / software platform (PC, switch, etc.) and IT
electronics equipments
Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT,
Broadband, Wireless)
Point-to-Point video-conferencing system (may be portable)

7.3.2. LEVEL-2: District Hospital

Telemedicine room
Patient engagement facilities (bed, scopes, etc.)
Telemedicine Platform
o Selective medical and medico-IT equipments, preferably IT compatible,
with interface to Telemedicine and/or other IT software / hardware
o Computer hardware / software platform (PC, server, switch, etc.) and IT
electronics equipments
Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broad
band, Wireless)
Multi-point video conferencing system
Optional telemedicine software access facility at consultants room through
Hospital-LAN
Optional secure centralized long-term electronic record storage for assigned
LEVEL-1 and LEVEL-M units

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 Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT,
Broadband, Wireless)
Note that:
o District Hospital may act as referring/consulting unit as well and may
have some medical equipments for tele-consultation with State Hospital /
National Super Specialty Hospital
o All units will require multiple telemedicine stations for simultaneous tele-
consultation with referring units

7.3.3. LEVEL-3: State Hospital / National Super Specialty Hospital

Telemedicine room
Telemedicine Platform
o Computer hardware / software platform (PC, server, switch, etc.) and IT
electronics equipments
Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broad
band, Wireless)
Multi-point video conferencing system
Optional telemedicine software access facility at consultants room through
Hospital-LAN
Optional secure centralized long-term electronic record storage for assigned
LEVEL-1, LEVEL-2, and LEVEL-M units
Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT,
Broadband, Wireless)
Note that:
o All units will require multiple telemedicine stations for simultaneous tele-
consultation with referring units

7.3.4. LEVEL-M: Mobile Telemedicine Unit *

Automobile Vehicle
o Chasis Size: 5.779 X 2.188 X 1.900 mts
o Customized fabrication to accommodate IT and medical equipments
o Integrated DG set
o Space for tele-consultation, patient examination
o Space for carrying out investigation procedures like Ultra-sonography and
X-ray
Telemedicine Platform
o Selective medical and medico-IT equipments, preferably IT compatible,
with interface to Telemedicine and/or other IT software / hardware
o Computer hardware / software platform (PC, server, switch, etc.) and IT
electronics equipments
Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT,
Broadband, Wireless)
Point-to-Point video-conferencing system (may be portable)
Besides vans, Mobile Telemedicine units can be customized for
deployment in any of the following:

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 oBoat (e.g. for application on back water regions in Kerala or in
Brahmaputra in Assam)
o Chhakras (e.g. used in Gujarat)
o Camel Carts (e.g. in deserts of Rajasthan)
Application specific mobile units can be configured:
o Tele-ophthalmology
o Tele-Cancer care
o Tele-Ambulance for Trauma Network and Rural Emergency system
o Suitcase-based Telemedicine module for Disaster-hit area, etc.
o Mobile hand held units to act as data harvesting point for NRHM at the
grass-root level

* Each state will have initially 02-04 units depending on the size and population.
Alternatively, the mobile vans procured under NRHM may be made telemedicine-
enabled with suitable modifications and installations.

7.3.5. NRHM Smart Card

At low investment, we can have the rural citizen health record incorporating life time
health events starting from cradle to grave. Hence, this device integration under Rural
Telemedicine network may be considered.

7.4. Process and Infrastructure Guidelines at Different Layers of Hierarchy

7.4.1. Telemedicine Process for LEVEL-M and LEVEL-1 units

The proposed Mobile Telemedicine Unit, Primary Health Center (PHC) / Taluk
Hospital are rural based health center catering to rural population. The Mobile
Telemedicine Unit is understandably mobile version of similar setup at PHC / CHC.

Through LEVEL-M and LEVEL-1 telemedicine consultation center, patients data

and reports can be sent to District Hospital and get the second / expert opinion.
Typically, these centers do not have very good diagnostic facilities, hence, some basic
equipment outlined below needs to be installed wherever not present.

Communication link between LEVEL-1 and District Hospital (LEVEL-2) could be

through Wi-MAX, Broadband, or V-SAT connectivity depending on availability. A
sustained bandwidth of 512 kbps or more for videoconference and data transmission
is deemed sufficient.

Basic setup will have a single multimedia computer system and IP-based Video
conference system with PTZ facility. Diagnostic reports of the patient are forwarded
to District Hospital using the telemedicine software system. Film Scanner may be
used for sending X-ray / CT / MRI images and Tele-microscopy system to send smear
for parasite in blood and urine for bacteriological studies. Additionally, a digital ECG
device may also be provided. A basic printer may also be provided for printing report
and records for distribution to patient.

The telemedicine functionality at these units may be either:

A self-sufficient system with ability to create and maintain long-term
electronic medical record (EMR) of patient, view, connect, transmit, and
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 retrieve expert opinion. This model supports offline, online, and interactive
telemedicine creating complete technological base of all types of services /
modalities.
A web-based / thin-client access to Servers at LEVEL-2. This model
supports offline, and web-based telemedicine creating sufficient and cost-
effective technological base of all types of services / modalities. However,
in this model, the unit should be able to locally create new record of new
patient (some type of reduced function but still usable) in case of
disconnection with LEVEL-2 servers. The locally created records should
be uploaded to LEVEL-2 server when connectivity is restored.

7.4.2. Telemedicine Process for LEVEL-2 and LEVEL-3 units

The proposed setup at District Hospital (LEVEL-2) has dual purpose. It acts as a
referral unit for all LEVEL-1 and LEVEL-M units assigned to it. It also acts as a data
collection and referring unit for LEVEL-3 units. Film Scanner may be used for
sending X-ray / CT / MRI images and Tele-microscopy system to send smear for
parasite in blood and urine for bacteriological studies. Additionally, a digital ECG
device may also be provided. A mid-size printer may also be provided for printing
report and records for distribution to patient and provide hard-copy reports to experts /
specialist for discussion / deliberation.

The LEVEL-3 units are purely referral in nature and provide expert opinion on data
sent from District Hospitals or those generated at PHC level and then forwarded by
District Hospitals assigned to it.

Due to nature of these units being referral in nature, with multiple lower level units
connecting, transmitting data, and requiring expert opinion / intervention, it is
necessary to provide multiple telemedicine stations at these locations. These units will
have multi-point video-conferencing system so that it can cater to various locations at
a time.

Communication link between LEVEL-2 and LEVEL-3 units can be over terrestrial
fiber optic cables, Wi-MAX, Broadband, ISDN, or V-SAT connectivity depending on
availability. A sustained bandwidth of 512 kbps or more for videoconference and 256
kbps per simultaneous data transmission is deemed sufficient.

Setup at each such location will consist of a Server (or a Server farm in case of large
load) with multiple client / access units for telemedicine. Fail-safe long-term data
storage servers to store data generated at local location and lower-levels need to be
established. To promote anytime/anywhere telemedicine access, all consultants in the
program should be provided with access support at their room in hospital through
hospital LAN. Additionally, some active consultants may be provided dial-up or Wi-
Fi access from a laptop depending on nearness to the facility.

The telemedicine functionality at these units may be either:

A Server / Client system with ability to create and maintain long-term
electronic medical record (EMR) of patient, view, connect,
receive/transmit, and retrieve/send expert opinion. This model supports
offline, online, and interactive telemedicine creating complete
technological base of all types of services / modalities. A web-based access
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 system for consultant from their room or via laptop/home may also be
provided.
A web-based Server system having all facility to allow local consultant
and remote LEVEL-1 and LEVEL-M doctors to connect, create, store,
retrieve EMR and provide/retrieve expert opinion. This model supports
offline, and web-based telemedicine creating sufficient and cost-effective
technological base of all types of services / modalities.

7.4.3. Telemedicine Hardware / Software Requirement at LEVEL-M and

LEVEL-1

S.N. Item Qty

1. Desktop PC platform 01
Intel Core2 2.4GHz (or equivalent), 1024MB RAM,
400GB SATA2 HDD, DVD-RW Drive, 10/100/1000
NIC
Appropriate 3rd party Software (AV, personal
database)
Windows XP Professional, MS Office Standard
Hardware Accelerator Graphics Card (dedicated
256MB onboard RAM)
Keyboard and mouse (Optionally Wireless)
19 TFT LCD monitor
Suitable Web-Camera for interaction during Online
Tele-Consultation
Microphone, Stereo Speakers and Headset
2. Peripherals Laser Printer, 4-port USB Hub, etc. 01
Network device 8 port 10/100/1000 Mbps switch
and patch cables
1 KVA Line-interactive UPS
3. IP Video Conferencing Kit 01
128 Kbps IP based VC unit
29 LCD TV (with wall mounting kit)
4. Telemedicine software (either of following) 01
Interactive Self-sufficient (with remote interactive
connect to LEVEL-2 units)
Local Web-based reduced-functionality module (with
connectivity to remote Web-based Server)
5. Digital ECG 01
A3 Film Scanner
Digital Microscope
Digital Camera
Glucometer
Non-invasive Pulse & Blood Pressure unit
Additionally Mobile Van will have
o Ophthalmoscope
o Mobile USG
o Portable X-ray Unit with CR
o Haematogram Analyser

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6. Connectivity device (either of them) 01
ISDN Modem (with NT)
ADSL2+ / CDMA / PSTN Modem
VSAT SkyIP unit
Wi-MAX CPE
Fiber Optic CPE
7. Optionally 2/4 module router with items in S.N. 6 01
(in case of multiple connectivity medium)
In case of ISDN lines, dial-up router must be taken

7.4.4. Telemedicine Hardware / Software Requirement at LEVEL-2

S.N. Item Qty

1. Telemedicine Server Platform 01
2x Dual Core Intel Xeon 3.2 GHz (or equivalent),
4096MB RAM, DVD-RW Drive, Dual 10/100/1000
NIC, Remote management
Appropriate 3rd party Software (AV)
Operating System (depending on telemedicine solution
chosen):
o Windows 2003 R2 Standard Server, MS Office
Standard, MS SQL Server
o RedHat Enterprise Linux 5 Standard, PostgreSQL
Integrated Graphics Card
Wireless Keyboard and mouse
19 TFT LCD monitor
Onboard RAID Controller and Hot-swap disks
o 2x 36 GB SCSI / SAS RAID-1 for OS
o 4x 300 GB SCSI / SAS RAID-6
2. Optional Telemedicine Central Data Storage Server 01
(may be combined with S.N. 1 with spec increase)
Dual Core Intel Xeon 3.2 GHz (or equivalent),
2096MB RAM, DVD-RW Drive, Dual 10/100/1000
NIC, Remote management
Appropriate 3rd party Software (AV, Database)
Operating System (depending on telemedicine solution
chosen):
o Windows 2003 R2 Standard Server
o RedHat Enterprise Linux 5 Standard
Integrated Graphics Card
Wireless Keyboard and mouse
19 TFT LCD monitor
Onboard RAID Controller and Hot-swap disks (may
be on separate enclosure)
o 2x 80 GB SATA2 RAID-1 for OS
o 12x 500 GB SATA2 RAID-6
3. Optional Tape Library and Backup system 01
Ultrium 3 Technology
6 TB Native Backup capacity
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 SCSI Interface
Backup software with appropriate agents
4. Desktop PC platform 03
Intel Core2 2.4GHz (or equivalent), 1024MB RAM,
400GB HDD, DVD-ROM Drive, 10/100 NIC
Appropriate 3rd party Software (AV, Database)
Windows XP Professional, MS Office Standard
Hardware Accelerator Graphics Card (dedicated
256MB onboard RAM)
Wireless Keyboard and mouse
19 TFT LCD monitor
Suitable Web-Camera for interaction during Online
Tele-Consultation
Microphone, Stereo Speakers and Headset
5. Peripherals Laser Printer, 4-port USB Hub, etc. 01
Network device 8 port 10/100 Mbps switch and
patch cables
4 KVA On-Line UPS
6. IP Video Conferencing Kit 01
512 Kbps IP based VC unit
32 LCD TV (with wall mounting kit)
7. Telemedicine Client software (either of following) 01
Interactive Telemedicine Client (with interactive
connect to Telemedicine Server)
Local Web-based access (with connectivity to Web-
based Server)
8. Telemedicine Server software (either of following)
Interactive Telemedicine Serve with Web access
module
Web-based Telemedicine Serve
9. Digital ECG 01
A3 Film Scanner
Digital Microscope
Digital Camera
Glucometer
Non-invasive Pulse & Blood Pressure unit
10. Connectivity device (either of them) 01
ISDN Modem (with NT)
ADSL2+ / CDMA / PSTN Modem
VSAT SkyIP unit
Wi-MAX CPE
Fiber Optic CPE
11. Optionally 2/4 module router with items in S.N. 6 01
(in case of multiple connectivity medium)
In case of ISDN lines, dial-up router must be taken

7.4.5. Telemedicine Hardware / Software Requirement at LEVEL-3

S.N. Item Qty

14
1. Telemedicine Server Platform 01
2x Dual Core Intel Xeon 3.2 GHz (or equivalent),
4096MB RAM, DVD-RW Drive, Dual 10/100/1000
NIC, Remote management
Appropriate 3rd party Software (AV)
Operating System (depending on telemedicine solution
chosen):
o Windows 2003 R2 Standard Server, MS Office
Standard, MS SQL Server
o RedHat Enterprise Linux 5 Standard, PostgreSQL
Integrated Graphics Card
Wireless Keyboard and mouse
19 TFT LCD monitor
Onboard RAID Controller and Hot-swap disks
o 2x 36 GB SCSI / SAS RAID-1 for OS
o 4x 300 GB SCSI / SAS RAID-6
2. Desktop PC platform 03
Intel Core2 2.4GHz (or equivalent), 1024MB RAM,
400GB HDD, DVD-ROM Drive, 10/100 NIC
Appropriate 3rd party Software (AV, Database)
Windows XP Professional, MS Office Standard
Hardware Accelerator Graphics Card (dedicated
256MB onboard RAM)
Wireless Keyboard and mouse
19 TFT LCD monitor
Suitable Web-Camera for interaction during Online
Tele-Consultation
Microphone, Stereo Speakers and Headset
3. Peripherals Laser Printer, 4-port USB Hub, etc. 01
Network device 8 port 10/100 Mbps switch and
patch cables
2 KVA On-Line UPS
4. IP Video Conferencing Kit 01
512 Kbps IP based VC unit
32 LCD TV (with wall mounting kit)
5. Telemedicine Client software (either of following) 01
Interactive Telemedicine Client (with interactive
connect to Telemedicine Server)
Local Web-based access (with connectivity to Web-
based Server)
6. Telemedicine Server software (either of following)
Interactive Telemedicine Serve with Web access
module
Web-based Telemedicine Serve
7. Connectivity device (either of them) 01
ISDN Modem (with NT)
ADSL2+ / CDMA / PSTN Modem
VSAT SkyIP unit
Wi-MAX CPE
Fiber Optic CPE
15
8. Optionally 2/4 module router with items in S.N. 6 01
(in case of multiple connectivity medium)
In case of ISDN lines, dial-up router must be taken

7.5. Proposed Organizational Plan

7.5.1. Preparation of Infrastructure, E-Health Education and Training

Adequate physical infrastructure is now made available in many of the rural PHCs /
CHCs and District hospitals with World Bank aid under Health System Development
project. Even many district hospitals have now advanced medical equipments
including CT scan, Coloured Doppler etc. Under NRHM health worker and
professional capacity is building up. However, Ministry of Health & Family Welfare
has to play the key role in ensuring e-readiness both in terms of physical infrastructure
and e health education & training at all levels of hospitals before starting clinical
telemedicine process.

The bandwidth and communication infrastructure is crucial for the success of the
program. Communication agencies that have nationwide footprint (e.g. BSNL) need
to be roped in for providing connectivity at all location with internal virtual routes
between all units. In such a scenario, only last mile connectivity is to be provided
while a nationwide network is already in place.

Simultaneously, some Medical training institute should also be made part of the
program to promote CME and self-paced training program for Anganwadi / local
health workers and doctors at LEVEL-M, LEVEL-1, and LEVEL-2. The training can
be delivered over the same network.

7.5.2. Setting Guidelines for Administration and Clinical, Educational and

Governance Telemedicine Practices

The MoH&FW should appoint a National Director (with adequate seniority level)
for the program advised / assisted by a nuclear expert panel of people / organizational
representatives experienced in Telemedicine program planning and role-out.
Similarly, a State Director (with adequate seniority level) reporting to the National
Director should be appointed to ensure smooth role-out and functioning of the
program. A District Director at LEVEL-1 and LEVEL-M shall ensure programs
success.

The nucleus framework Recommendation on Guidelines, Standards and Practices

for Telemedicine in India. Specifies various guidelines that need to be followed by
all units for proper functioning.

7.5.3. Identification of Vendor for Project Implementation

There are various Telemedicine technology providers in the country. DIT, MCIT has
funded some very successful Telemedicine programs in the nation and may be
consulted on selecting a suitable Telemedicine technology platform for adaptation in

16
the program. It is important that chosen technology is supported and sustained,
preferably by a national technology agency, for the period of program and beyond it.

Once the Telemedicine technology platform is identified, then selection of other

hardware and software should be done in close consultation with chosen technology
provider. However, a mechanism of open tender should be encouraged in purchase of
identified hardware and software.

The implementing agency need to have national reach and experience in executing
Telemedicine project.

7.5.4. Recruitment of Technical / Medical Manpower

The manpower employed for the program are very crucial to the success of program.
In case manpower is drawn from existing strength / positions, a mechanism of
incentives need to be put in place that will encourage staff to engage fruitfully. All
appointments can be on term contract basis with periodic performance review.

7.5.5. Installation of Equipments, Network Media, Testing, Training and Hand-

Holding

Site identification, preparation, and installation will be taken in phased manner. The
implementer shall provide for at least 6 months of hand-holding to the deployed
location. Hand-holding can be done remotely. A training, as appropriate according to
function / role, need to be provided to staff on the program by implementing agency.

7.5.6. Periodic Monitoring and Preparation of Interim Report

The program directors will be responsible for monitoring the program throughout its
implementation and use period.

7.5.7. Impact Evaluation at the End of Each Year and After Five Year

A suitable mechanism to review effectiveness of program at end of each year and a

broad review at the end of 5 year period need to be done by program directors and
report be prepared for placing before MoH&FW.

17
8. BUDGET REQUIREMENT

The project needs to be implemented in phases.

8.1. Financial Requirement for Phase-I

During the first phase of the project, it is proposed to link up following in Phase-I:

100 LEVEL-1 (PHC / CHC / Village) units

50 LEVEL-2 (District Hospitals) units
5 LEVEL-3 (State Hospitals / Super Specialty Hospitals) units
50 Mobile Telemedicine Van (01 per District Hospital in program)

The financial requirement of Phase-I will consist of the cost for setting up
Telemedicine facilities, recurring cost for operation and maintenance, and their
connectivity charges.

8.2. LEVEL-1 (PHC / CHC / Village) Units

Fixed Costs

18
Sl. Item Description Estimated Value Remarks
No. (In Rupees)
1. Recommended Medical 6,00,000 The list of
Equipment equipment are
given at Sec 7.4
2. Hardware / Software (including 3,50,00
PC server, etc.)
3. Telemedicine Consulting Center 2,00,000 May vary,
(TCC ) software Interactive Self-
Sufficient is
assumed. Web-
based module may
be cheaper.
4. Video Conferencing Kit 2, 50,000
5. Terrestrial IP (512 kbps) scalable 10,000 May vary,
Broadband setup
charge assumed.
6. Land, building, furniture 0 To be provided by
electrical fittings, fixtures or any the hospital
other non electronic item concerned
7. Training costs 50,000 To be provided by
vendor, hospital
bears cost of its
staff.
8. Installation & Commissioning 1,00,000 To be conducted by
various vendors.
Total 15,60,000

Annual Recurring Costs

Sl.No Item Description Approximate Cost Remarks

(in Rupees)
1. Site Administrator + Technician 3,50,000 Administrator=
Rs2,00,000
Technician = RS
1,50,000
2. Medical staff incentive / 1,08,000 Doctors (01 nos) =
allowance 5000/month
Medical staff (02
nos) = 2000/month
2. Annual Maintenance Charges 2,00,000 Assuming 15% of
Hardware/software per node Equipment costs +
s/w subscription /
update
3. Annual Update / Support 40,000 Assuming 20% of
Charges of Telemedicine costs
software
3. Annual bandwidth cost per year 50, 000 Assumed
per node Broadband
4. Electricity, other consumables, 0 To be provided by
etc the hospital
19
Total (with incentives) 7,48,000
Total (without incentives) 6,40,000

20
8.3. LEVEL-M (Mobile Telemedicine Van)

Fixed Costs

21
Sl. Item Description Estimated Value Remarks
No. (In Rupees)
1. Automobile Van with integrated 25,00,000
DG set, bed and other provisions
2. Recommended Medical 36,00,000 The list of
Equipment equipment are
given at Sec 7.4
3. Hardware / Software (including 3,50,00
PC server, etc.)
4. Telemedicine Consulting Center 2,00,000 May vary,
(TCC ) software Interactive Self-
Sufficient is
assumed. Web-
based module may
be cheaper.
5. Video Conferencing Kit 2, 50,000
6. Terrestrial IP (512 kbps) scalable 10,000 May vary,
Broadband setup
charge assumed.
7. Van Equipment integration 1,00,000
8. Training costs 50,000 To be provided by
vendor, hospital
bears cost of its
staff.
9. Installation & Commissioning 1,00,000 To be conducted by
various vendors.
Total 71,60,000

Annual Recurring Costs

Sl.No Item Description Approximate Cost Remarks

(in Rupees)
1. Site Administrator + Technician 4,46,000 Administrator=
+ Van operator 2,00,000
Technician = RS
1,50,000
Operator=96,000
2. Medical staff incentive / 1,56,000 Doctors (01 nos) =
allowance 8000/month
Medical staff (02
nos) = 2500/month
2. Annual Maintenance Charges 6,30,000 Assuming 15% of
Hardware/software per node Equipment costs +
s/w subscription /
update
3. Annual Update / Support 40,000 Assuming 20% of
Charges of Telemedicine costs
software
3. Annual bandwidth cost per year 50, 000 Assumed
per node Broadband
4. Fuel, Van maintenance 0 To be provided by
the hospital
22
Total (with incentives) 13,22,000
Total (without incentives) 11,66,000

23
8.4. LEVEL-2 (District Hospitals)

Fixed Cost

24
Sl. Item Description Estimated Remarks
No. Value (In
Rupees)
1. Recommended Medical 6,00,000 The list of equipment are
Equipment given at Sec 7.4
2. Hardware / Software 11,50,00
(including PC, servers, etc.)
3. Optional Storage Server + 8,00,000
Backup
4. Telemedicine Consulting 7,50,000 May vary, Interactive
Center (TCC ) software Client is assumed. Web-
based module may be
cheaper.
5. Telemedicine Server Software 5,00,000
4. Video Conferencing Kit 8, 50,000
5. Terrestrial IP (2 mbps) scalable 10,000 May vary, Broadband
setup charge assumed.
6. Land, building, furniture 0 To be provided by the
electrical fittings, fixtures or hospital concerned
any other non electronic item
7. Training costs 1,00,000 To be provided by
vendor, hospital bears
cost of its staff.
8. Installation & Commissioning 2,00,000 To be conducted by
various vendors.
Total (with optional items) 49,60,000
Total (without optional item) 41,60,000

Annual Recurring Costs

Sl.No Item Description Approximate Cost Remarks

(in Rupees)
1. Site Administrator + Technician 3,50,000 Administrator=
Rs2,00,000
Technician = RS
1,50,000
2. Medical staff incentive / 1,08,000 Doctors (01 nos) =
allowance 5000/month
Medical staff (02
nos) = 2000/month
2. Annual Maintenance Charges 5,56,500 Assuming 15% of
Hardware/software per node Equipment costs +
s/w subscription /
update
3. Annual Update / Support 2,50,000 Assuming 20% of
Charges of Telemedicine costs
software
3. Annual bandwidth cost per year 1,50, 000 Assumed
per node Broadband
4. Electricity, other consumables, 0 To be provided by
etc the hospital

25
Total (with incentives) 14,14,500
Total (without incentives) 13,06,500

26
8.5. LEVEL-3 (State Hospital /Super Specialist Hospitals)

Fixed Cost

27
Sl. Item Description Estimated Remarks
No. Value (In
Rupees)
1. Recommended Medical 0 No medical equipment
Equipment
2. Hardware / Software 11,00,00
(including PC, servers, etc.)
3. Telemedicine Consulting 7,50,000 May vary, Interactive
Center (TCC ) software Client is assumed. Web-
based module may be
cheaper.
4. Telemedicine Server Software 5,00,000
5. Video Conferencing Kit 8, 50,000
6. Terrestrial IP (2 mbps) scalable 10,000 May vary, Broadband
setup charge assumed.
7. Land, building, furniture 0 To be provided by the
electrical fittings, fixtures or hospital concerned
any other non electronic item
8. Training costs 1,00,000 To be provided by
vendor, hospital bears
cost of its staff.
9. Installation & Commissioning 2,00,000 To be conducted by
various vendors.
Total 35,10,000

Annual Recurring Costs

Sl.No Item Description Approximate Cost Remarks

(in Rupees)
1. Site Administrator + Technician 3,50,000 Administrator=
Rs2,00,000
Technician = RS
1,50,000
2. Medical staff incentive / 1,08,000 Doctors (01 nos) =
allowance 5000/month
Medical staff (02
nos) = 2000/month
2. Annual Maintenance Charges 3,39,000 Assuming 15% of
Hardware/software per node Equipment costs +
s/w subscription /
update
3. Annual Update / Support 2,50,000 Assuming 20% of
Charges of Telemedicine costs
software
3. Annual bandwidth cost per year 1,50, 000 Assumed
per node Broadband
4. Electricity, other consumables, 0 To be provided by
etc the hospital
Total (with incentives) 11,97,000
Total (without incentives) 10,89,000

28
29
8.6. Financial Summary

Although there are various varying components in the tentative budget provisions
given above, here the maximum value per unit is taken to know the extent of budget.
Communication setup and running cost may change completely depending on the type
of connectivity chosen finally.

Unit Fixed Recurring Qty Total

LEVEL-M 71,60,000 13,22,000 50 42,41,00,000
LEVEL-1 15,60,00 07,48,000 100 09,04,00,000
LEVEL-2 49,60,000 14,14,500 50 31,87,25,000
LEVEL-3 35,10,000 11,97,000 5 02,35,35,000
Total 205 85,67,60,000

The total budget (using maximum component valve, except connectivity) come to
around Rupees Eight-Five Crore Sixty-Seven Lakhs Sixty Thousand only.

30