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1. Diagnose and Treat Strokes Faster

The lack of clear-cut legal guidelines, rules, and regulations hinders the telemedicine to improve healthcare access and healthcare quality through information and communication technology [ 31 ]. Story is different if we look from the side of providers or healthcare organizations.

For establishing a telemedicine unit, it needs lots of financial investment. It becomes more difficult for the developing countries to allocate huge budget for the investment in telemedicine. There are many other costs are involve in delivering teleconsultation like payment of Internet and electricity bills, salary of support staff, other recurring costs etc. These total costs are so high that many proposals of establishing or starting telemedicine program never take off, or even if it starts, it dies soon and cannot sustain on a long-term basis.

Many telemedicine pilot projects have failed because of high maintenance cost [ 14 ]. The costs of telemedicine are often high in developing countries, because of low awareness between both patients and local healthcare workers, low information technology literacy, and limited access to infrastructure and technology [ 27 ]. Telemedicine service providers are generally unable to bear all costs alone and expect government or development partner to support financially for the sustainability of the telemedicine projects. Most of the telemedicine solutions and programs tend to be government funded, at least in their initial phases.

Due to some reasons, if government stops funding, the system becomes unsustainable as there is no alternative business model. So dependency on public support is another financial barrier in the development of telemedicine in developing countries [ 27 ]. Cost incurred in purchase, installation, and maintenance of telemedicine services telemedicine and communication equipment are very high and do not give proper return on investment ROI , so there is less economic benefits to the practitioners, which leads to the bankruptcy and closure of many health facilities in rural communities and also prevents further telemedicine expansion to communities needing specialized services [ 32 ].

Insurance companies do not reimburse the teleconsultation bills and payments, which further force the practitioners to stop the telemedicine services. Many hospitals and clinics perceive that telemedicine solutions are too expensive to implement. Reimbursement of telemedicine services has been reported as one of the important barriers in developed countries [ 17 , 22 , 33 , 34 ]. When patient avails healthcare services through telemedicine system, insurance claim may not cover the cost of care as it is not delivered through traditional healthcare system. Such discrimination seldom occurs in developing countries, where health insurance is still a rare commodity [ 30 ].

Social and culture milieu of the community and society of a particular country also creates lots of barriers in adapting, utilizing, and sustaining telemedicine services. The lack of ICT literacy, awareness, language barriers, and cultural gaps between the service providers and patients etc. A lack of support to newer ICT tools has been observed from both parties providers and users.

In developing countries where general literacy is not even adequate, we can imagine the awareness level of population toward ITC literacy. Poor awareness toward modern technologies and their use in delivering health care seems to be a big barrier in developing countries. People in developing countries are not much aware about the benefits offered by telemedicine. Even physicians are short of IT knowledge and not updated. Poor awareness level creates fears and resistance toward ICT technology and create hurdle in the adoption and development of telemedicine.

Telemedicine: Ed Brown, CEO, Ontario Telemedicine Network's point of view

Age also plays an important role. Many older physicians do not feel comfortable dealing with ICT technology. Some patients, particularly older patients, are hesitant about the new technology. Many healthcare professionals are not comfortable working with computers and modern gadgets and consider technology extra work for them. They also fear that telemedicine may lead to job loss or a reduction in their bedside presence [ 27 , 33 ]. There is lack of confidence in patients about the outcome of telemedicine.

It is difficult for them to believe that machine can provide healthcare demands without visiting physician face to face [ 25 ]. This cultural perception and attitude toward newer technology also possess threat to the development of telemedicine. Even many physicians also think that patient consultation and treatment are incomplete without touching the patient and prefer face-to-face consultation than remote consultation through ICT platform. Some medical practitioners do not want to opt telemedicine practice due to the fear of medical indemnity.

Barriers to adoption and sustainability of rural telehealth embody several factors that must be considered when planning, developing, implementing, and evaluating a rural telehealth program [ 32 ]. There are three players in the telemedicine viz. One of the major hurdles of development of telemedicine in developing countries is the passiveness of provider physician and users.

Most of the telemedicine tools and technologies are developed and supplied by the developed countries and they have strong market influence in the developing countries. IT industry people are very active and try to influence policy makers and administrators in the health system to sell their IT technology telemedicine-related hardware and software. Their focus is only to sell and install the telemedicine tools and equipment and leave the system for the physician to run. Failure is bound to happen if providers and users are not taken into account while developing the telemedicine platform.

For example, in Madhya Pradesh, India, ISRO and top-level administrators at ministry level decided to implement telemedicine solutions across the state but it failed badly as there were no takers at ground level. Physicians were not convinced and adequately trained for newer technology and public as a user was not aware about the benefit of the platform [ 14 ]. Health care in developing countries is in the midst of a paradigm shift, from a traditional provider-centered, disease-oriented approach to a patient-centered, health-management model.

10 Ways Telemedicine Is Changing Healthcare IT | CIO

Telemedicine has influenced almost all aspects of healthcare and many success stories have reported the role of telemedicine in improving healthcare access, reducing cost of care, and enhancing the quality of care. Telemedicine could be an important tool in achieving healthcare coordination and reducing healthcare disparities. Despite of so much development and successful work in the field of telemedicine, it has yet to become integral part of healthcare system. Success of telemedicine only depends when it becomes integral part of healthcare delivery system and not as a stand-alone project.

Now, it is time to take telemedicine from pilot mode to routine operational mode in mainstream health services delivery system. There is tremendous pressure on governments to provide accessible affordable and quality healthcare to its people. Only alternative and innovative methods like telemedicine can help to fulfill this gap. Current status of telemedicine in developing countries is not very satisfactory and passing through a stage of crisis.

This chapter has explored the various barriers in the development of telemedicine in developing countries.

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These various barriers mentioned above are impeding the speed of expansion of telemedicine in developing countries. It is now time to minimize the abovementioned barriers and remove the bottlenecks for smooth development of telemedicine network across the globe for the betterment of humanity. The author would like to thank the Department of Public Health and Family Welfare Madhya Pradesh and National Health Mission Madhya Pradesh for providing funding support to conduct telemedicine evaluation survey from where experience has been shared here.

The author declares that he has no competing interest with anyone in publishing this chapter. Help us write another book on this subject and reach those readers. Login to your personal dashboard for more detailed statistics on your publications. Edited by Thomas F. We are IntechOpen, the world's leading publisher of Open Access books. Built by scientists, for scientists. Our readership spans scientists, professors, researchers, librarians, and students, as well as business professionals.

Downloaded: Abstract Affordability, accessibility, availability, and quality of healthcare services have always been a burning issue for the mankind. Keywords telehealth telemedicine barriers developing countries health care.

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Introduction Increasing population in the developing countries has created more demand of health care. Barriers to telemedicine programs 1. Policy barriers For smooth functioning and development of any system, we need to have definite policies and procedures at State and National level. Organizational structure Lack of formal organizational structure to deliver telemedicine services is the biggest barrier for the development of telemedicine services in any country.

Lack of accreditation or regulatory bodies There is no specificity and standardization in the practice of telemedicine, which poses accreditation issue. Lack of team of champions Once telemedicine system is deployed and is placed, then there is a need of project champions, who will implement the telemedicine program. Lack of telemedicine champions There is a paucity of dedicated, focused, and visionary telemedicine leaders in developing countries.

Lack of clinical champions: physicians Training is an import part of skill development and the organizations should develop a training schedule to train health professionals for smooth delivery of telemedicine services [ 21 ]. Lack of paraclinical champions: nurse providers Telemedicine health services are also assisted or provided by nursing staff but their contribution in telemedicine is not recognized and acknowledged.

Lack of IT champions: teletechnicians Telemedicine is a hybrid system, which involves the medical as well as ICT domain for complete understanding of the telemedicine solutions and its delivery. Technological barriers Technology itself is becoming a barrier in the development of telemedicine in developing countries. Rapid upgradation of ICT Due to rapid advancement of telemedicine technology, many state-of-the-art facilities and equipment software and hardware become obsolete and outdated.

Inadequate ICT infrastructure Many developing countries have inadequate availability of Information and Communication Technology ICT such as computers, Internet network, printers, and electricity for proper implementation and running of telemedicine program. Initial huge start-up cost of ICT infrastructure Telemedicine set up can deploy varieties of information and communication technologies ICTs for transmitting information through texts, pictures, audios, and videos to a variety of healthcare providers.

Low Internet connectivity Most of the telemedicine applications require a high speed and reliable Internet bandwidth to run smoothly. Legal barriers Telemedicine practices has eliminated many physical and emotional barriers to healthcare seeking but have raised many legal and ethical issues, which are normally not encountered during traditional healthcare delivery.

Online prescription There is no legal framework of e-prescription, digital prescription, or mobile-based SMS prescription. Malpractice liability Most of the doctors are afraid of Consumer Protection Act due to malpractice-related issues. Some of them allow customizing its functionality thanks to a Linux software platform and specific SDKs.

The degree of customization reachable without incurring the cost of SDK, inferred by tests, is not adequate for the project needs. A netbook represents the best tradeoff among all metrics. All missing interfaces, or future extensions, can be added by USB connector. The only drawback is the keyboard, whose keys are too small and too many with respect to the request.

The operating system chosen for the gateway is based on Linux kernel 2. The H H software runs directly when netbook is switched on. The main concerns of the system were implemented in separated threads to ensure a high modularity and the maximum flexibility when combining them in any arbitrary operating protocol. This modular architecture ensures easy maintenance and upgrades, including future extensions with new sensors or the introduction of new communication standards. The newly developed OP concept consists of a set of actions, like taking measurements or replying to simple questions, that the patient must follow during the monitoring period as well as it completely defines the behavior of the home gateway in terms of types and frequencies of measurements transmission policy, selectable symptoms, comparison thresholds, and phone numbers for each alarm.

The OP is tailored by the physician at the beginning of the monitoring period and it can be remotely updated in progress according to the patient conditions. In fact at the end of any data transmission, if necessary, the server is able to update the current operating protocol by sending the new one to the interested gateway. The OP update and the consequently reconfiguration of the gateway is totally transparent to the user.

Usual values for measuring frequencies and ranges for alarms detection are shown in Table 2 , but clinicians can configure each parameter. Sensor data signal processing, implemented in the home gateway, is in charge of detecting alterations in vital signs potentially dangerous for the patient. Data processing involves three main steps: preprocessing, analysis and cry wolf avoidance. The preprocessing consists of the filtering of raw data provided by the sensors, removal of noise and main interference, and the extraction of derived information.

The analysis step compares the outcome of the preprocessing with the thresholds defined in the OP that establish the admissibility range for punctual values or trends over a medium period. The last step is useful to reduce the number of false positive alarms, for example due to temporary stress or sensors misuse.

In the presence of abnormal values, the same measurement is shortly deferred and only if the condition is confirmed the gateway raises the alarm, contacting caregiver or health professionals via SMS. The required arithmetic precision is compliant with real-time implementation on bit single-core processor and the RAM memory available in the netbook.

All involved algorithms have a linear complexity with the number of considered samples of the signal, both in terms of memory and computational cycles. The electrocardiographic signal is treated to extract maximum, minimum, and average heart rate over the track as well as to detect the presence of atrial fibrillation.

The reference point within the ECG signal is the QRS complex: three deflections that occur periodically and in rapid succession, where the R point represents the main upward ones. A derivative-based algorithm [ 37 ] and a rule-based system [ 38 ] for the QRS complex detection are applied.

Afterwards, the signal is differentiated, squared, and averaged. Comparing the averaged signal against a threshold creates a set of windows that allow to recognize the R peaks in the filtered signal maximum positive within the window. The R peak has still passed through a rule-based system that evaluates whether the detected QRS is a valid QRS complex or not based on the distance in time between consecutive peaks.

Figures 7 a and 7 b show the raw and filtered signal. There is also a cubic spline data interpolation algorithm that extracts the envelope of the R peaks as an indirect indication of the respiratory activity. Figure 7 c shows the envelope signal of the peaks. The analysis of the intervals between consecutive R peaks, using a 30 seconds window shifted along the time axis by 5 seconds length steps [ 39 ], allows to calculate the heart rate. Concerning SpO2 signal analysis, relevant values are maximum, minimum, and also the average level of oxygen saturation over the track, extracted by a digital low-pass FIR filter.

Concerning blood pressure signal processing, systolic and diastolic values are analyzed see Figure 8 to find out under or over threshold situations and the general trends of both parameters are verified looking for suspicious variability that are typical manifestation of cardiac instability. As far as weight, this parameter is easy to measure and elaborate as well as very effective in the CHF management. It allows to detect fluid retention in the patient.

The user interface has an essential role in this application having to guide the patient in following the scheduled measurements or drugs assumptions. The developed home gateway provides an intuitive user interface able to display guide images, reminder messages, and sounds when a planned activity time is reached. Figure 9 shows the appearance of the graphical interface. Patients can read the last measured values of weight, blood pressure, heart rate, and oxygen saturation.

At the top of Figure 9 the reminder textbox indicates the requested activity, along with the graphical helper that shows the correct actions to be done as gif animation. The other textboxes report the status of the related sensor, included battery charge. Green, yellow, and red textboxes background colors are used for information, warning, and error messages, respectively.

In idle state the time of the next activity is visualized. The custom keypad allows to navigate and confirm symptoms in case of manual alarm or extra measure and to answer questions about pills therapy. The H H server platform is a web-based application that receives data from gateways, providing a detailed process of analysis based on expert systems and finally the update of the patient record in the departmental HIS.

No summarization function is provided, but it deals with all the received unaggregated data. Moreover the H H server platform exports interfaces that allow the clinicians to interact with the system, retrieve information and manage all patients. Two possible ways of integration with existing HIS are available see Figure 10 in order to improve the interoperability of the system.


In the first mode, called synchronous request SR , all data are stored locally in the H H server platform and vital signs are provided on-demand as result of query messages submitted from the HIS. Queries address a dedicated service endpoint and use XML to specify the searching parameters: the patient identification, the vital signs, and the time interval. The second mode, the automatic notification AN method, requires that the HIS interested in receiving the clinical information coming from the gateways exposes a dedicated webservice reachable by the H H software platform.

From the functional point of view the software platform is composed of two main parts: the core and the frontend. The frontend represents the human machine interface for the physicians see Figure Its main functions are related to the patient management since their enrolment, when the physician inserts the patient data and configures his OP. To be noted that user interfaces at both home gateway and server sides have been realized in different languages English, Italian, Slovenian, Spanish to allow the installation of the system in the National Health Systems of the different project partners.

At any time the physician is able to look through the patient clinical folder, comparing the patient health status in different periods by means of measurement trends. The system is able to highlight the alarms encountered during the monitoring. If necessary the physician can modify the OP at any time, this produces an automatic and transparent update of the gateway.

The frontend is based on the rich client technology which allows defining a simple user interface with high performance from the user interactivity point of view. The architecture is able to completely decouple application logic from data displaying, in order to make the interface fast, flexible, and usable by the user. Conceptually, the browser provides the features of a desktop application accessible from the Internet without installing any add-on. The visual components, written in Java Script, are downloaded at runtime and run locally into the browser.

The core part is based on the Spring Framework [ 40 ] which accepts patient measurements collected and sent by the gateways through a dedicated webservice endpoint. All received messages are formally verified and the contained observations are stored in the local database. Additionally the core is responsible for data retrieval when requested by the frontend. Data between the core and the frontend is exchanged through Java Script Object Notation. Finally the core exposes an additional service useful when a gateway has to be customized for new users.

As data exchanged between gateway and server involves the public Internet, the use of HTTPS protocol fits completely the requirements of confidentiality, authenticity, and integrity for the data traffic.

The protocol also meets perfectly the web service paradigm: the request message contains all pending results and events within its body, coded according to the HL7-RIM CDA v2, while the response includes the XML description of the current OP, allowing remote updates after each transmission.

The header of the CDA document contains information about the patient, used to address its EHR, and the recipient hospital. Result and Vital Signs sections contain numeric and waveform observation blocks, one for each measure. The InterpretationCode tag is used to mark normal or abnormal values.

Mobile Telemedicine: A Computing and Networking Perspective

Symptoms are hosted as event observations in the Purpose section. Medical equipment section describes the sensing devices used. Transmission occurs according to the OP, at the end of an activity, or on time-base i. Communication occurs also when the gateway has to be configured for a new patient. The server replies with all the information of the given patient and the personal OP. Now the configuration is complete, the reachability of the endpoints is tested and the monitoring can start. Using this procedure, patient information and operating protocol are defined only once at server-side, reducing the possibility of mistakes.

The H H system follows a very structured and incremental testing procedure concluded with the final technical validation and demonstration phase. Unit test of hardware components and operational correctness of software and firmware applications using conventional procedures were the first steps. The following integration test verified the end-to-end communication in the system and the overall system-level interactions of the different HW and SW parts. To this aim some ad hoc prepared scenarios and the involvement of healthy users were used.

The last important phase before the final technical demonstration was the alpha-testing: two patients minimally aware of ICT and younger than the CHF average age 1 month. The first impressions of physicians and patients coming from these tests made possible to tune the final version of the system. Acute coronary syndrome within 3 months before the enrolment was the only exclusion criteria. The minimum period of monitoring was one month. The metrics established for the evaluation of the system belong to two main categories: objective and subjective.

The first ones are related to items unequivocally measurable, the latter depend on the personal experience during the demonstration and the feeling with the system. A specific testing protocol and a questionnaire to collect patients, caregivers, and physicians feedbacks were used to validate the system. A group of selected cardiologist checked out the information arrival in HIS, evaluating the quality and coherence of data collected and the relevance of the alarms.

On the other hand the robustness and reliability of data transmission and the effectiveness from the medical point of view were evaluated. No connectivity and transmission problems occurred, including data or sensors network configuration lost. Following that study, others sought to model the cost-related aspects of stroke care for spoke and hub institutions more specifically with and without a telestroke network in place.

The analysis assumed a single hub and a 7-spoke network. In brief, with the telestroke network in place, the model predicted that approximately fewer stroke patients would be admitted to the hub hospital each year, whereas approximately 16 more patients would be admitted to each spoke hospital compared with a no-network setting.

The model predicted that approximately 45 more patients would be expected to be treated with intravenous thrombolysis and 20 more with endovascular stroke therapy in a telestroke network per year. Overall, the results of this study suggest that a telestroke network may be an effective and financially tenable way to extend the reach of stroke specialists to remote areas and thus to improve the overall quality of care for stroke patients.

Furthermore, it seems that each of the many telestroke networks that now exist have different technology in place to fit their idiosyncratic practice needs. The technological aspects of a telestroke network are of interest because there has been growth in the telestroke-related telecommunications market within the last decade, and the cost thereof remains one of the most consistently identified barriers to implementation of a telestroke network.

In spite of a robust and growing evidence base supporting the use of telemedicine in general and telestroke in particular, there are a host of legal considerations that constitute a barrier to more widespread implementation. Among them are disparate licensing and credentialing requirements between each state or nation.

The Eleventh International Conference on eHealth, Telemedicine, and Social Medicine

In the US, a physician must be licensed in the state in which a patient seeks care. Thus, a telemedicine physician must be licensed in each and every state involved in the telemedicine network. Many of the legal and legislative issues exist for the use of telemedicine in general, but there are some that are particularly relevant to telestroke. Some who are wary of developing a telestroke network cite the lack of legal clarity at a federal level or even in most states regarding shared liability between hub and spoke sites in the case of a bad outcome.

For the case of acute stroke, because it seems that the majority of stroke-related lawsuits come from rt-PA not being administered, institution of a process that affords emergency medicine providers access to stroke specialists and has been shown to increase rt-PA use should mitigate this concern. That said, there is still a role for establishing clear legal agreements between hub and spoke sites, be they via federal law or on an individual basis. Telemedicine allows a provider to extend expertise far and wide, skirting geographical barriers, and has the potential to facilitate more timely, efficient, and effective care to all, irrespective of medical specialty.

The physical and logistical considerations of the general practitioner making house calls via horse-drawn carriage seem truly antiquated in the era of 4G wireless infrastructure; however, some basic principles of provider-patient interaction that we as providers have espoused since those house-call days remain entirely relevant to telemedical practice. More specifically, we as physicians cannot allow anything—telemedicine or otherwise—to jeopardize the ineffable healing power of an empathy-driven interaction with a patient. Ostensibly, an inability to touch a shoulder or overtly display sympathetic body language to the patient and their loved ones might disallow the nontechnical aspects of a medical consultation.

That said, a telemedical consultation can be conducted in such a fashion as to maximize empathic interaction, with language and deliberate physical gestures to make up for an inability to tacitly convey our sympathies as we otherwise might in person. At the time of this writing, at least one study of perceived empathy through telemedical consultation is actively enrolling, and a second study of patient and provider satisfaction with telemedicine is being designed.

We hope that these studies and others will demonstrate that, with a commitment to empathic care on the part of a provider, the provider-patient relationship does not substantially differ between in-person and telemedical consultation. More than a decade since its published conceptualization, there is now a robust and growing literature base that supports the use of telestroke in mainstream clinical stroke practice.

Of particular interest is the role of prehospital telestroke for diagnosis of a large-artery stroke syndrome in patients who might benefit from early triage to endovascular reperfusion therapy. Further study is recommended to establish minimum technical standards for in- and prehospital telestroke use.

The use of telestroke videoconferencing infrastructure for education of trainees and the community at large about acute stroke evaluation and management also remains largely unstudied. Perhaps most importantly, there is a paucity of randomized trials and cost analyses, which might otherwise serve to buttress the practice and dissolve barriers to the implementation of telestroke.