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INTRODUCTION

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.
The terms e-health and telehealth are at times wrongly interchanged with telemedicine. Like
the terms "medicine" and "health care", telemedicine often refers only to the provision of
clinical services while the term tele health can refer to clinical and non-clinical services such
as medical education, administration, and research. The term e-health is often, particularly in
the UK and Europe, used as an umbrella term that includes tele health, electronic medical
records, and other components of health IT.

WHAT IS TELEMEDICINE?
“The delivery of health care services, where distance is a critical factor, by all health care
professionals using information and communication technologies for the exchange of valid
information for diagnosis, treatment and prevention of diseases and injuries, research and
evaluation and for the continuing education of the health care providers all in the interest of
advancing the health of individuals and communities.

EARLY PRECURSORS
In its early manifestations, African villagers used smoke signals to warn people to stay away
from the village in case of serious disease. In the early 1900s, people living in remote areas
of Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to
communicate with the Royal Flying Doctor Service of Australia.
TYPES OF TELEMEDICINE
Categories
Telemedicine can be broken into three main categories: Store-And-Forward, Remote
Monitoring And (Real-Time) Interactive Services.
Store-and-forward telemedicine involves acquiring medical data (like medical
images, biosignals etc.) and then transmitting this data to a doctor or medical specialist at a
convenient time for assessment offline. It does not require the presence of both parties at the
same time. Dermatology (cf: teledermatology), radiology, and pathology are common
specialties that are conducive to asynchronous telemedicine. A properly structured medical
record preferably in electronic form should be a component of this transfer. A key difference
between traditional in-person patient meetings and telemedicine encounters is the omission
of an actual physical examination and history. The 'store-and-forward' process requires the
clinician to rely on a history report and audio/video information in lieu of a physical
examination.
Remote monitoring, also known as self-monitoring or testing, enables medical professionals
to monitor a patient remotely using various technological devices. This method is primarily
used for managing chronic diseases or specific conditions, such as heart disease, diabetes
mellitus, or asthma. These services can provide comparable health outcomes to traditional in-
person patient encounters, supply greater satisfaction to patients, and may be cost-effective.
Interactive telemedicine services provide real-time interactions between patient and
provider, to include phone conversations, online communication and home visits. Many
activities such as history review, physical examination, psychiatric evaluations and
ophthalmology assessments can be conducted comparably to those done in traditional face-
to-face visits.

TELEMEDICINE IN INDIA
We in India are unable to provide even total primary medical care in rural areas .secondary
and tertiary medical care is not uniformly available even in suburban and urban areas.
Incentives to entice specialists to practice even in suburban areas have failed.
In contrast to the bleak scenario in health care, computer literacy is developing quickly in
india . healthcare providers are now looking at telemedicine as their newly found avatar.
Theoretically, it is far easier to set up an excellent telecommunication infrastructure in sub
urban and rural India than to place hundreds of medical specialists in these places . it is also
realized that the future of telecommunication lies in satellite based technology and fiber
optic cables.
THE BEGINNING
The Apollo group of hospitals was a pioneer in starting a pilot project at a secondary level
hospital in a village called Aragonda 16 km from chitoor(population 5000,Aragonda project)
in Andhra Pradesh. Strating from simple web cameras and ISDN telephone lines today,the
village hospital has a state –of-the –art video conferencing system and a VSAT(very small
aperature terminal)satellite installed by ISRO. Coupled with this was the Sriharikota space
centre project(130 km from chennai)which formed an important launch pad of the Indian
space research organisation in this field.
CURRENT EFFORTS
In india , telemedicine programs are actively supported by Department of Information
Technology (DIT)

 Indian Space Research Organization

 NEC Telemedicine program for North-Eastern states
 Apollo Hospitals
 Asia Heart Foundation
 State governments
 Telemedicine technology also supported by some other private organizations

DIT as a facilitator with the long-term objective of effective utilization / incorporation of

Information Technology (IT) in all major sectors, has taken the following leads in
Telemedicine:

 Development of Technology
 Initiation of pilot schemes-Selected Specialty, e.g., Oncology, Tropical Diseases and
 General telemedicine system covering all specialties
 Standardization
 Framework for building IT Infrastructure in health

The telemedicine software system has also been developed by the Centre for Development of
Advanced Computing, C-DAC which supports Tele-Cardiology, Tele-Radiology and Tele-
Pathology etc. It uses ISDN, VSAT, POTS and is used to connect the three premier Medical
Institutes of the country (viz. All India Institute of Medical Sciences (AIIMS), New Delhi,
Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow and Post
Graduate Institute of Medical Education and Research (PGIMER), Chandigarh). Now it is
being connected to include Medical centres in Rohtak, Shimla and Cuttack.
In the past three years, ISRO's telemedicine network has expanded to connect 45 remote and
rural hospitals and 15 superspecialty hospitals. The remote / rural nodes include the offshore
islands of Andaman and Nicobar and Lakshadweep, the mountainous and hilly regions of
Jammu and Kashmir including Kargil and Leh, Medical College hospitals in Orissa and some
of the rural / district hospitals in the mainland states
The Rabindranath Institute at Kolkata and Narayana Hrudayalaya at Bangalore will be the
main Telemedicine linking hub for the seven states. The specialists at both the institutions
will offer their services for this project entirely free of charge. A 100 bedded hospital will be
identified in each of these seven states and the hospitals will be selected based on distance
from the state capital and the lack of a coronary care unit.
In the past two years, the pilot project on Telemedicine in Karnataka has already provided
more than 10,000 teleconsultations. In the operational phase, the Karnataka Telemedicine
Project is expected to bring multi-specialty healthcare to a significant section of the rural
population of Karnataka. This network would serve as a model for the utilization of
‘HEALTHSAT,’ which is proposed for launch in the future.

ttettte

TELE COMMUNICATION TECHNOLOGIES

The first among the challenging questions arising when planning a telemedicine network is
‘What is bandwidth?’ Bandwidth is the capacity that determines how quickly bits may be
sent down the channels in a telecommunication medium. Bandwidth is proportional to the
complexity of the data for a given level of system performance. The following technologies
are currently in use:

INTEGRATED SERVICES DIGITAL NETWORK

ISDN is a dial-up (not dedicated but used on a call-by-call basis) digital connection to the
telecommunication carrier. An ISDN line can carry information at nearly five times the
fastest rate achievable using analog modems over POTS (plain old telephone service).

T-1

This is the backbone of digital service provided to the end user (typically business) in USA today
which transmits voice and data digitally at 1.554 megabits per second (Mbps). It can be used to carry
analog and digital voice, data and video signals and can even be configured for ISDN service

PLAIN OLD TELEPHONE SERVICE (POTS)

POTS transmits data at a rate of up to 56 kilobits per second (kbps) and is the most widely
available telecommunication technology in the world. POTS can be suitable for audio
conferencing, store-and-forward communication, Internet and low bandwidth videophone
conferencing.

INTERNET

The Internet has a strong impact in delivering certain kinds of care to patients. In a survey of
1,000 Chief Intelligence Officers (CIOs) conducted by Internet Health Care Magazine, 65%
said their organization had a Web presence and another 24% had one in development. With
the increasing proliferation of e-health sites on the Web today, many consumers are finding
access to online patient scheduling, health education, review of lab work and even e-mail
consultations.
BENEFITS AND USES
o Telemedicine can be extremely beneficial for people living in isolated communities
and remote regions and is currently being applied in virtually all medical domains.
Patients who live in such areas can be seen by a doctor or specialist, who can provide
an accurate and complete examination, while the patient may not have to travel or
wait the normal distances or times like those from conventional hospital
o Telemedicine can be used as a teaching tool, by which experienced medical staff can
observe, show and instruct medical staff in another location, more effective or faster
examination techniques. It improved access to healthcare for patients in remote
location.
o Telemedicine has been shown to reduce the cost of healthcare and increase efficiency
through better management of chronic diseases, shared health professional staffing,
reduced travel times, and fewer or shorter hospital stays.
o In addition to objective technological monitoring, most tele monitoring programs
include subjective questioning regarding the patient's health and comfort.
o Tele monitoring is capable of providing information about any vital signs, as long as
the patient has the necessary monitoring equipment at his or her location

The major areas were telemedicine technology adopted:

 Tele consultation:
 Tele diagnosis:
 Tele treatment:

The patient with local doctor consults the specialists,obtains the line of treatment

 Tele education
 Tele training
For continuing medical education,t raining for doctors and paramedics from a higher level
hospital/institution

 Tele monitoring:regular monitoring for intensive care and emergency care

 Tele support : support during disaster

CHALLENGES

 Perspective of medical practitioners: Doctors are not fully convinced and familiar
with e-medicine.

 Patients' fear and unfamiliarity: There is a lack of confidence in patients about the
outcome of e-Medicine.
 Financial unavailability: The technology and communication costs being too high,
sometimes make Telemedicine financially unfeasible.
 Lack of basic amenities: In India, nearly 40% of population lives below the poverty
level. Basic amenities like transportation, electricity, telecommunication, safe
drinking water, primary health services, etc. are missing. No technological
advancement can change anything when a person has nothing to change.
 Literacy rate and diversity in languages: Only 65.38% of India's population is
literate with only 2% being well-versed in English.
 Technical constraints: e-medicine supported by various types of software and
hardware still needs to mature. For correct diagnosis and pacing of data, we require
advanced biological sensors and more bandwidth support.
  Quality aspect: “Quality is the essence” and every one wants it but this can
sometimes create problems. In case of healthcare, there is no proper governing body
to form guidelines in this respect and motivate the organizations to follow-it is solely
left to organizations on how they take it.
 Government Support: The government has limitations and so do private enterprises.
Any technology in its primary stage needs care and support. Only the government has
the resources and the power to help it survive and grow. There is no such initiative
taken by the government to develop it.

TELE NURSING
What is tele nursing?
Telenursing is a component of telehealth that occurs when nurses meet the health needs of
clients, using information, communication and web-based systems. It has been defined as the
delivery, management and coordination of care and services provided via information and
telecommunication technologies .
Technologies used in telenursing may include, but are not limited to:
• telephones (land lines and cellphones)
• personal digital assistants (PDas)
• facsimile machines (faxes)
• Internet
• video and audio conferencing
• computer information systems
What are the principles of telenursing?
These guidelines are based on the principles of telenursing, which state that effective
telenursing should:
• augment existing healthcare services
• enhance optimum access and, where appropriate and necessary, provide immediate access
to healthcare services
•follow position descriptions that clearly define comprehensive, yet flexible roles and
responsibilities
• improve and/or enhance the quality of care
• reduce the delivery of unnecessary health services
•protect the confidentiality/privacy and security of information related to nurse-client
interactions.

Pro’s and con’s of tele nursing

 it increases public access to health services, especially for people living in rural areas
and those with compromised health status.
 It is also proposed that telenursing will decrease waiting times, reduce unnecessary
visits to emergency rooms and physicians’ offices,
 enable clients to leave hospitals sooner or stay at home longer before becoming
institutionalized,
 potentially reduce costs for public travel and professional overhead expenses.
 another benefit cited includes the immediacy of information provided to clients to
help them meet their healthcare needs.

other potentially Negative Impacts raised in relation to telehealth include:

• likelihood of technology failures
• increased risks to the security and confidentiality of clients’ health information and records
• potential for health providers to step outside their scopes of practice
• inability (increased difficulty) to provide clients with information to allow them to make
informed decisions about whether to give or refuse consent
• responsibilities of employers to ensure personnel have the necessary competencies
• consideration for additional professional liability insurance if clients are located in another
province or country
Should nurses practising telenursing be concerned about Liability and risk
management?
Whether nurses engage in e-health, internet-based practice or other technologies, they will
face new and constant challenges, including potential issues of liability. although a lack of
legal precedents creates uncertainty about liability in telehealth, clearly defined
accountabilities will be key to dealing with several recognized categories of liability,
including those related to:
• health professionals involved
• specific technologies/applications used
• organizations or institutions involved
• human resources and training nurses providing care via telehealth also need to be involved
in the development and documentation of risk management plans and related policies.
Risk management in terms of telehealth could include ensuring the security and integrity
with the use of disclaimers being of particular importance
Is liability protection an issue in telenursing?
face-to-face interactions are still considered to be the best way to ensure accurate
communications between nurses and clients Given this, the importance of developing
policies to support safe, competent, compassionate and ethical telenursing cannot be
overstated. examples of further policy development and/or practices needed to help reduce
liability risks include:
• using consistent tools to collect data
• using evidence-based, protocol-driven software or data to support telenursing
• consulting other care providers when appropriate (e.g., “when in doubt, check it out”).
The need for additional liability protection for nurses practising telenursing depends on a
number of factors, such as the:
• types of technology to be used (e.g., Internet)
• services to be provided (e.g., expanded scope of practice)
• location of the clients (e.g., outside of Canada)
• employment status of the registered nurse (e.g., self-employed)
Competencies Required To Ensure Safe Telenursing Practice

 personal characteristics (e.g., positive attitude, open-mindedness towards technology

 and good people skills) that will facilitate their involvement and advance the
telehealth program
 knowledge and ability to navigate the technology system and environment (e.g., the
knowledge and skill to properly operate hand-held cameras, videoconferencing
equipment, computers, etc.)
 an understanding of the limitations of the technology being used (e.g., able to
determine if vital signs are being monitored accurately by specific equipment)
 the ability to recognize when telehealth approaches are not appropriate for a client’s
needs
  ability to modify clients’ care plans based on above noted assessments
 awareness of client risks associated with telehealth and willingness to develop back-
up plans and safeguards
 knowledge, understanding and application of telehealth operational protocols and
procedures
 competent enhanced communication skills
 appropriate video/telephone behaviours
 awareness of the evidence base for their practice and areas of practice in need of
research

Security, Confidentiality/Privacy
In terms of telenursing, security, confidentiality and privacy are of utmost importance not
only in terms of nurses’ interactions with clients, b ut also in ensuring that the technologies
themselves are secure (e.g., minimal risk of hacker ‘intrusions’). To ensure clients’
information remains confidential and private, it is vital that clients’ records be adequately
protected (e.g., secure in electronic and/or written format). The amount and type of security
measures required will depend on the mode of technologies used in telenursing practice (e.g.,
Internet, e-mail).

CONCLUSION
As models of care delivery continue to change and new technologies emerge,
TELENURSING practice will continue to evolve. In turn, as the scope of nursing practice
further expands, registered nurses will need to ensure that they possess the necessary
technical and clinical competencies to practise telenusing safely, competently,
compassionately and ethically.
It does not require too much of a stretch of imagination to realize that TELEMEDICINE
will soon be just another way to see a health professional. Remote monitoring has the
potential to make every minute count by gathering clinical data from many patients
simultaneously. However, information may be lost due to a software glitch or hardware
meltdown. Therefore, relying too heavily on a computer system to prevent errors in
healthcare data may be problematic. There has to be a smart balance between total
dependence on computer solutions and the use of human intelligence. Striking that balance
may make all the difference in saving someone's life. In 2008, the potential of telemedicine,
tele-health and e-health is still left to our imaginations. Time alone will tell that Telemedicine
 is a “forward step in a backward direction” or to paraphrase Neil Armstrong “one small step
for IT but one giant leap for Healthcare”.

CLASS PRESENTATION ON

TELE MEDICINE &

TELE NURSING
SUBMITTED TO: SUBMITTED BY:

Ms Preethy jawahar Ms Gishy Vijayakumar

Lecturer 1st year Msc Nursing

MCON,Manipal MCON, Manipal

SUBMITTED ON:

29/03/2012

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