Details for Reform Option "Telemedicine scheme for cardiac emergencies, Karnataka"
Studies suggest that Indians are genetically three times more vulnerable to heart attacks than Europeans and Americans. Those living in rural areas run the greatest risk of misdiagnosis of symptoms or delay in receiving treatment.
Chamarajanagar, a tribal, border district of Karnataka, is one of the most underdeveloped districts in the State. The District Hospital, Chamarajanagar has 70 beds, 15 doctors and the capacity to treat over 250 out patients a day. The hospital has facilities for general medical and surgical treatments, yet patients with any emergency cardiac condition had to travel at least 60 kilometres to Mysore for treatment, thereby losing the 6 crucial hours after a heart attack when a blood clot can be broken down and the life saved.
According to Dr Devi Shetty, cardiac surgeon and managing director of Narayana Hrudayalaya super speciality hospital in Bangalore, 99% of patients do not require operations. In these cases there is no need for the doctor to be physically present, all data can be transferred electronically through a system known as telemedicine.
The Karnataka Telemedicine Programme was formally launched in April 2002 in association with the Indian Space Research Organisation (ISRO) to provide better emergency cardiac care to underserved areas such as Chamrajanagar. Under the project, remote hospitals and health centres are linked via satellites to super speciality hospitals in major cities, connecting patients with specialist doctors for consultations and treatment.
The Telemedicine Cardiac Care Unit (CCU) at District Hospital Chamarajanagar opened its doors in February 2002. One online ECG machine was purchased complete with the computer hardware provided by Narayana Hrudayalaya and ISRO and two other regular ECG machines were supplied by the World Bank-supported Karnataka Health System Development Project (KHSDP).
The telemedicine system consists of customized medical software integrated with computer hardware, along with diagnostic instruments connected to the Very Small Aperture Terminal (VSAT) at each location. This facility enables transmission of patients’ medical records, including images, and provides a live two-way audio and video link between patient and specialist. VSAT connectivity has no geographical barriers and doesn’t require a telephone line.
Once the patient’s history is sent to the specialist doctor, along with investigative data such as interpretation of images and blood chemistry, he can communicate with the patient and attending doctor during a video conference. He can advise on the course of treatment to be followed and can even provide guidance during surgery.
Between February 2002 and March 2005 the Chamrajanagar CCU has achieved the following:
i) Thrombolysed 187 cases with acute Myocardial Infraction (MI)
ii) Treated 945 other cardiac cases including MI as inpatients
This includes cases such as acute coronary syndrome, congenital and rheumatic heart diseases and arrhythmias.
iii) Screened, reviewed and treated 16,668 outpatient cases
iv) Organised 10 free cardiac diagnostic camps in Chamarajanagar district, with the help of Narayana Hrudayalaya
v) Enabled 74 patients to undergo invasive cardiac procedures at Narayana Hrudayalaya, of which eight were operated upon totally free or for a nominal fee.
vi) Enabled more than 338 patients to get higher cardiac evaluation at Narayana Hrudayalaya at its free outpatients department
vii) Average occupancy for cardiac care throughout the year 60.32%
Two computers and accessories: INR 100,000
Scanner: INR 130,000
Conferencing Camera: INR 250,000
Digital camera INR 65,000
The bulk of the cost for technology oriented services goes on software. Narayana Hrudayalaya (NH) has developed its own software which is given to the general practitioners, hospitals or charitable organisations free of charge.
VSAT equipment was provided to the District Hospital, Chamarajanagar by ISRO free of cost. (It would otherwise have cost around INR 15 lakh (€ ) for a 385kbs line.)
Computers and tele-conferencing unit were given by NH in association with ISRO free of charge.
Chamarajanagar district, Karnataka
Two weeks to set up the telemedicine equipment (mainly VSAT) and convert the building from a general ward to a CCU
Speed: Patients can be diagnosed and treated quickly, without the need for a potentially life-threatening journey to a larger hospital.
Economical: In terms of cost of travel to a hospital for a second opinion and in service itself, once facility set up.
Service extended: Referral process strengthened and specialist advice available at PHC level.
Steamlines referral: Patients are able to see the right doctor without falling prey to ineffectual untrained practitioners.
Continued medical education: Staff and doctors can keep pace with ongoing advances in medicine from the convenience of their office.
Builds trust: Patients with low level of education are often suspicious of visiting a city specialist. Tele-conferencing offers frequent consultation with the specialist, building confidence and improving patients’ compliance to treatment.
Lack of technical support: It can take weeks for telemedicine equipment in rural areas to be repaired.
Staff unwillingness: GPs find problems seeking and accepting advice from a specialist whom they don’t know personally. (This could be over come by holding an orientation course for GPs at the hospital giving the specialist consultation).
Communication barrier: Patients with little acquaintance with conferencing equipment may find it difficult to talk to the ‘video image’ of the specialist.
Broadband connectivity, needed for video conferencing facility though not for data transfer.
Telemedicine training facility.
Funds to set up the facility.
Political initiative and backing.
Who needs to be consulted
State and district level government, hospital doctors.
Sustainable,since in the context of rural and distant areas, telemedicine-based medical care is highly cost effective once equipment has been installed.
Sustainability depends upon maintenance of equipment and upkeep of the CCU facility, including consumables, medicines and staff salaries (if not government employees, as at Chamarajanagar).
Chamarajanagar CCU levies user charges for telemedicine services. These exclude consultation and doctor’s fee.
i) ECG 30/-INR
ii) Bed charge 100/- INR per day
iii) Streptokinase Injection 1,100/- INR
iv) Ventilator charges: 500/- per day
Below poverty line (BPL) patients are exempt from all charges.
Chamarajanagar CCU has so far accrued about INR 400,000 after meeting all its maintenance costs.
Chances of Replication
Very good. There are now about 80 remote district hospitals linked to 29 super speciality hospitals throughout India. There are a further 10 in other countries. Using this technology, Narayana Hrudayalaya says 17,500 patients have been treated so far.
As in rural areas across India, more than 90% of Chamrajanagar’s population is dependent on agriculture. For such people living at subsistence level, health comes as a low priority. Medical staff report that providing adequate health care to them is increasingly challenging. Tele-medicine is proving to be an affordable and reliable method of getting treatment for these people.
Tessa Laughton, Research Consultant, ECTA, New Delhi, May 2005.