In analyzing any new legislation or a Government project, meant to transform the society, it is necessary to consider its impact on the society from the specific point of whether it would improve harmony in the society or create social tensions.

In an IT project implementation, the "Digital Divide Factor" is the reflection of this concern. Will the new legislation increase the divide between the Digital haves and Digital have nots? If so, how to bridge this gap so that social tensions do not raise to a level of disturbing the society are essential factors to be considered.

Let us therefore look at the Telemedicine guidelines from the point of its impact on the Digital Divide factor.

Telemedicine For Whom?

India has a set of Metros which are well equipped with medical facilities. These are also the cities where high bandwidth communication facilities are available and there are corporate hospitals which have the resources to buy hardware and software to conduct Telemedicine practice.

However, the need for experts to be consulted online is not critical in these cities since experts are available locally in every disciplines and if critical, professionals are available to visit within a short time. Documents can also be moved around physically without much delay. Conventional consultancy arrangements do therefore take care of all the critical needs of patients.

Thus telemedicinal consultancy is not critical for this segment of the society except if consulting a foreign expert is required.

On the other hand, lack of medical expertise is felt more in the rural India where qualified doctors may not be available and transport system may be inadequate.

The focus of Tele Medicine in India should therefore be to deliver better quality health services to the rural sector. This may mean that the services should be available at places with minimum telecommunication facility and low end equipments.

To be more specific, it is not a crying need that a CT Scan report taken in Chennai should be forwarded to a super expert in Delhi online for a report on the fly rather than to get an X-ray from a village to reach a midlevel expert in a nearby city for immediate instructions on first level attention before the patient reaches better facilities.

Does the Telemedicine guideline recognize this need? Or Does it focus on the need for a Politician in Apollo Hospital who wants to consult a specialist in Chicago? If it does both, it is fine. But if it only helps the latter, then perhaps the Digital Divide will widen with the new guidelines.

At present there are no clear indications in the guidelines that it has recognized  the needs of Indian rural sector for better health delivery.

For example, the guidelines indicate that the "Minimum" bandwidth required for communication should be 128 Kbps with 95 % uptime. At present, this bandwidth would be available only if a dedicated Lease or DSL line is used. The conventional internet connectivity is lower than 56 Kbps. Hence the service is of use only to well equipped hospitals and not smaller rural medical centers or doctors working in remote places.

If these doctors have to take advantage of Tele Consultancy, then they should be able to use a normal web cam over a telephone modem to talk/video conference with the Consultant and if possible show him a few pictures from a normal digital camera. Obviously the quality of these pictures may fall short of expectations. But still, for the patient and the local doctor, this is a better way to consult than to only speak over phone.

There is a danger that the Tele medicinal guideline may not facilitate such interaction but rather  make such interactions illegal..

The technical standards suggested in the guideline will require new Tele Medicine Consultation Centers to be developed which are equipped with the necessary communication facility, video conferencing facility and also the necessary equipments. The cost of such centers would be higher than the cost of setting up a well equipped diagnostic center.

It appears that such centers would not be feasible as independent ventures in small towns. They may be viable only in cities or as part of a large hospital.

The guidelines in its present form will only help equipment manufacturers from abroad sell high cost equipments to Indian health industry as a replacement for the non compliant equipments that they may be using now.

It is therefore suggested that the Standards mentioned in the guidelines are reviewed so as to assist in the setting up of rural tele health consultancy centers which effectively work on 64 Kbps lines and with standard scanned images of print outs and transmission of scanned photographs and digital photographs of good resolution.

The only security required is to ensure that every transmission is digitally signed and encrypted with the use of Digital Certificates.

The data that some of the equipments such as the ECG etc generate as of now in electronic form should be transmitted as simple data and converted at the receiving end through appropriate applications into high quality pictures.

The technical approach of the guideline should therefore be to use ordinary equipments at one end and appropriate applications at the consultant's end.

If this is not done, the guideline may widen the digital divide, increase the cost of even the existing health care both in rural area and in cities and put legal hurdles for the rural doctors in consulting experts outside the suggested tele medicinal system.

Naavi

December 26, 2002

Related:

Is This an Indian Version of HIPAA?

The Essential Impact of the Telemedicine Legislation

Are We Ready for Telemedicine Regulation?

Telemedicine Draft Guidelines Released for Public Comment

Rs 2860 crores Outlay for SMART Governance ?-April 2002

Legal Issues of Tele-Medicine Practice October 2000