Updates II

The Ultimate Goal

The ultimate goal of telemedicine is to provide quality health care to anyone at anytime from anywhere, The patient benefits by getting medical attention, no matter to what degree it is, as soon as he wants it. The doctor benefits by being able to access information about a particular patient efficiently and quickly, perform a battery of demographical, statistical and other related medical calculation, look up relevant medical material and dispense the best possible medical treatment that he possibly can under a given circumstance.

This necessarily means change, something that really makes one most uncomfortable, to say the least. But change we must for this is a changing world. Tempora mutantur et nos mutamura im ellis - times change and we change with times. Else, we shall all be suffering from the terrible and terminal the boiled frog syndrome.              [Top]

A Scene from the Future

Well, this one is NOT a virtual scenario, for starters. It actually is a sneak peak at the future....
The future will be something as follows. The doctor sitting in his clinic or home or the nurse sitting at her station will be connected to the Internet using wireless connection. The computer will "wake up" and connect to the Internet as soon as either someone "calls him up" or he makes a call. He would also have a mobile that will double up as a palm-top with Internet connectivity using WAP, as would every other person (patients, paramedics, nursing staff, etc.). The various diagnostic centres (clinics or departments), surgery, CCU, ICU, CTU, Paediatric ICU,  would be connected to a server or a computer (hand-held or desktop device) that is connected to the Internet using WAP.          [Top]

Some Important Issues

Information Technology is, forgive the oft-repeated ad nauseam cliché, an ever-changing technology. So is everything that is even remotely related to it, including telemedicine. Although telemedicine per se is a means of delivering quality health care, it makes extensive use of the tools supplied by the IT community to make it more robust, cost-effective and efficient. Consequently, telemedicine too needs to be re-thought, re-visited, and if so needed, re-fashioned (this sometimes means going back to the drawing board for a complete re-design from scratch) of many its components.

WAP is on us. So is WML and WAP browsers. Actually it was already on us for quite a while now in the form of handheld PCs and laptop computers with which one could connect to the Net. We did not actually use the mobile phone more as a computer than a device merely to communicate whenever we felt inclined to do so (I do however suspect that we "got called up" more than we "called someone up" and it was not improving our quality of life - imagine relaxing in some quiet place and getting called up by someone who wanted the latest figures of some essentially useless information and one that would have not precipitated an immediate crisis, but I digress). However, soon we shall be using the mobile phone as a computer and (although this might seem to be blatantly borrowed concept based on the communicator of the famous series 'Star Trek'), with a small digital camera and an ear-phone to carry on a decent private conversation even when you have people milling all around you. The display screen will double up as a video-screen. Commands will be issued by speaking into the device (you already have devices that dials a number stored in its memory if you say "Hello so-and-so"...), and the device will access the information or connect you to someone via the Net, is so necessary.

Essentially, we shall all be on the Net (or should I possibly say Netizens living in cyberspace - the final frontier of the virtual world?) with our very own unique address (egad, we shall be mere numbers if we are not already!). This would, coupled with authentication by voice and data encryption will definitely increase security of transmissions. We shall have slots in the GSM's for smartcards that would allow us to pay online, serve as tickets to anything that we have paid for, etc.

So where is or what has telemedicine got to do with all this, do I hear you ask? Well, the same device can get you instant access to a doctor of your choice, any medical professional may get all the relevant information that he requires - the possibilities are really endless. The medical professional will need only to speak to the device that will act both as a dictaphone and a medical transcriptor moulded into one. Need a print out? No problem. Just say print and a suitable printer will print it all out for you. This printer could be located at your office or residence or wherever and if you have access to more than one printer you can ask a specific printer to print it! Long live the newest tech on the block - Bluetooth. I personally have a lot of hope for this technology as it promises so much. Well, so many have promised so much and delivered so little. I hope, Bluetooth shall not figure amongst one of them!

The smartcard can carry a lot of information and filling out a prescription will be so easy. The doctor will prescribe, this prescription will be delivered to a chemist's shop near you who will have it delivered to you. Quick access, quick relief.

There is a catch though to all this, when was there none? The doctor will, in most cases, need to examine you in person, although the touch-sensitive mice could be of some help, and you will still need to give your body-fluid sample (even if it is only a drop placed on a spot on the device). For scans you will still need to go to a place where it is done. Maybe in future, this would also be solved.              [Top]

Where do we stand at the end of the year 2000 and why?

I write these words with a sense of mixed feelings. It is Christmas Day (to be exact) and I am taking stock of what has happened since I worked with telemedicine back in early part of 1997.
I am glad to be able to say that of the four facilities that could be provided, three and three-quarters have been developed and implemented, although, as far as my knowledge goes, there is no one single web portal that provides all of them. One needs to visit various sites to access the various information sought. Some portals do however provide appropriate links to other sites, which is a much welcome relief to all end users.

This absence of a single all-purpose portal is reflective of various factors. Principally, there exists a number of types of healing, namely allopathic, homeopathic, naturopathic, transcendental (in the form of Yoga, Reiki, meditational, etc.), traditional (like Chinese, Japanese, Unani), Ayurvedic (I could have classified it as Indian traditional but the recent spurt in its universal acceptance, I decided otherwise), etc. Now, we may swear by any one of the above mentioned methods of healing and be dismissive of the rest, the fact of the matter is that they do make a definite difference in the patient's life and anything that accomplishes this has got to be acknowledged as being useful. Furthermore, even amongst any one of the methods, there exists various bodies of opinion, sometimes so diametrically opposed that one might jolly well think that they proponents are talking about two very different methods. Thus, there can be no one site that could provide a coherent viewpoint that might be acceptable to all.

The four had been - i) Providing online consultation (between doctor and clinical/para-clinical specialist and doctor and patient; ii) Providing health-related information to the general public online; iii) Providing Continuous Medical Education (CME) {I am particularly glad that even medical students are being helped in the process}along with a searchable database for pertinent medical information - like details of a condition, medicine, normal values of investigations, etc.; and iv) Patient Database Management System.

Since July 1999 (if I am not mistaken as to the time), health-related sites on the Internet have been the most visited ones - before that it was the ones that provided titillation and instant gratification of rather dubious nature. I had hoped that this given the fact since we love ourselves the most - all narcissists, that's what we as a race are - not my words, the words of a very revered professor of anatomy of mine where he extolled the virtues of learning anatomy and learning it well although it is regarded as a very drab subject by many a student who have passed through the portals of institutions imparting medical knowledge, one of whom has been yours truly.

So far so good. Now comes the sad part. I had foreseen but, the eternal optimist as I am, had rather hoped that PMRDMS (patient medical records data management system) too would become ubiquitous and popular inspite of the problems that lay in the path of it's successful implementation. Varying and ever-changing laws of the land have systematically put up almost insurmountable problems in the path of this becoming what it must become in order to telemedicine to truly deliver on its promise. Doctors regards, and rightly too, that a patient's data is sacrosanct. One must be like the Father Confessor as far as what the patient has told him, else he shall never get all the facts from history alone. Now, ask any decent medical professional worth his salt and he shall tell you in no uncertain terms, that only by itself, history more often than not will reveal the eventual diagnosis. History taking is the first thing they teach you in clinics and is the first thing any graduating medical student forgets. He subsequently learns the hard way, the importance of history-taking - both of present condition as well as of the past,   those of socio-economic and in cases of women their menstrual ones.

However, if the patient even gets a hint that there is even the slightest possibility that the information that he gives might become public, he will simply not tell his attending doctor. A good and smart doctor will and should be able to get it out of him, but then he would have to trick the patient into doing so - not a practise that can be recommended at any time, and worse must be self-taught.

Anyway, I digress. Any type of data, be it history or findings of investigation or diagnosis or the treatment given, is to be treated as being ultra-sensitive and must be stored as such -whether on paper, in a database or in the doctor's brain. I remember a discussion where a person stated in no uncertain terms that he would never give any information to a doctor who would store that information in a database residing on any computer. Strong words but made a lot of sense from the person's point of view. How can that doctor ensure that his database would not be hacked into and the data stolen. Well, the paper that the doctor writes on to and then files away into his filing cabinet could be hacked, er broken, into and the information stolen from there too. Yes, hacking into a computer can be done across continents, breaking and entering a doctor's clinic necessitates the hackers, er thief's, physical presence. Both however can be traced with adequate security in place, although the data can be used for many a nefarious purpose by then. So security of the records in the database needs to be ensured. There can be no question about that.

Designing a database to hold patient medical records is also proving to be a most tenuous one, to say the least. Many a far-sighted techno-savvy doctor have designed their own databases and it has been found that it is ideal for them and their purposes. However, they differ so much from each other that it is proving to be practically impossible to design one that suits all. Well, the approach should, in my opinion, be to design one with a minimum common denominator and then allowing the doctor to add to it to suit his purposes.

Allow me to illustrate what I mean by an example. Let us say that a certain patient, aged 50,  is a diabetic and hypertensive for the past 10 years. Well, he normally goes to his physician who ritualistically asks how he is doing, has there been any changes since he last came for a check-up, then checks his pulse rate, blood pressure, blood sugar and ECG. He stores this information into a database. The patient reveals during history-taking that he has been feeling breathless and occasional pain in the calf-muscles during walking. The physician refers him to a diabetologist and a cardiologist for further evaluation and advise regarding further management. Both of these specialists wish to have a look at the patient's past medical records.

First, the patient should give his consent. That done, "appropriate" information has to be passed on to the two specialist. Now, the inevitable question is, what is "appropriate"? The diabetologist would be more interested to know the blood sugar levels, what the patient's diet is and medication the patient is currently on. The cardiologist's interest would be on the pulse rate, blood pressure, ECG and the current medication and diet is. {There are a number of other things they would be interested in, but I would like to keep this example simple.} However, the diabetologist might be keen to know what the blood pressure of the patient has been for the past four months, while the cardiologist would be interested in the blood sugar levels for the past six months.

So the database has to be designed in such a manner that both the specialists may get the information that they are looking for by the click of a few buttons. Moreover, both of them are interested in the diet being taken by the patient as well as the current medication.

So the last two items mentioned are the minimum common denominator. They must be visible to both of them. The others must be displayed according to the pre-set choices as well as the requests that are made on the spur of the moment - a dynamic run-time decision. The security of the data being transferred must be maintained throughout though.

Different vendors would come up with different versions of the database. Which one will become the most used one will depend largely not only upon the product but on the way it is marketed and its ease-of-use. However, one thing must be ensured. The data security. There can be no compromise on this. Moreover, the vendors must be mindful of the fact that the patient, his physician and the specialists might be using competing products to access the data.

Unfortunately, most of what is on offer is either an alternative of a programme that runs on the doctor's  PC or an online one where one fills up all the pertinent information that is securely stored and can be retrieved online or faxed through once the patient goes through some authentication like entering an username/password or identification number, etc. The first is quite a costly one and is not really "value for money", the second one is a very poor substitute at best. ASPs (application service providers) could have a very big role to play to provide and maintain such records and this is one area that is going to gain the most attention. I hope it does else we may not see telemedicine in its full bloom in the very near future, i.e., by July 2001, and this would be tragic of epic proportions.

Well, not exactly what I had envisaged three years ago. That is why I had said at the beginning of this column that only three and three-quarters and not four of my initial proposals have been successfully implemented. There are at least two more that could be added though. What are they do I hear you say? Go figure, says I.

It always a small but the most vital piece of any puzzle is the most difficult to solve. More often than not, the solution is right in front of you and is very obvious, but completely missed.Yes, yes. I am aware I am toying with you, but then with the festive season and the imminent arrival of the new year does certainly "add to the mood" of throwing a bit of good cheer all around.                [Top]

Microprocessor-Chip-Enabled SmartCard Based Medical Data Management System

The purposel is to make available up-to-date medical (possibly including insurance and social-security) information using contact microprocessor-chip smartcards with the information displayed as per the user’s choice. The patients may easily carry these credit-card sized cards in their pockets.

These cards would allow access to the information stored within through a unique pin/password known only to its owner. Relevant information like a summary of the last visit to a health care providing centre, vital statistics, summary of significant past history, details of investigations and findings thereof, etc. could be downloaded on to these cards and handed over to the patient. The amount and type of information would of course ultimately depend upon the capacity of the smartcard. Additionally, insurance-related data could include various details like its limit, its balance, and its date of expiry etc. In fact, the amount of information that could be made available on the smartcard is essentially quite endless.

A link that connects to the main data-storage area where most, if not all data would physically resides, however needs to be made available that would allow one to connect, after proper authorisation of course, and retrieve/store data as and when necessary. This could be done using the Internet through a Secure Socket Layer/Secure Electronic Transaction or a Virtual Private Network. If money transaction can be securely carried out using the Net, medical data could be too.

Hand-held smartcard readers, apart from smartcard readers attached to the COM port of a PC may be used in isolation to read data off the cards. Compatible software, which is user-friendly and able to "read" cards from a variety of vendors, is of the utmost importance and the success of the facility depends heavily on this aspect alone. These smartcards for medical purposes could be an extension of the credit card or ID in itself. The same card could be used for both – a dual-purpose card.

Since most of the vital information required for emergency situations would always reside in the smartcard, the software that would read this information would allow it to be displayed in the language the person reading it would understand. Moreover, all information that this smartcard would allow access to, could be displayed in the language of choice of the person reading it. Emergency information could be read by anyone. For the detailed information access, the patient would have to indicate his consent by punching in their unique pin/password that would be exclusive to them.

For the general public without access to a PC and a modem-linked POTS (Plain Old Telephone System) at hand, cyber cafes, information kiosks or cash-point like machines could be used for contacting medical personnel by the patients for advise and treatment whenever they require. PC Keyboards with suitable interfaces for reading smart cards/fingerprints are already available commercially, and the medical professionals may be consulted "on-line" from the comfort of the one's residence.

This data could be used for performing statistical analysis and research and analysis by the medical personnel for providing ever-increasing level of quality healthcare.