Recipient Institution:
Research Group on Biomedical Engineering
Biomedical Engineering Programm
Department of Electrical Engineering
Institut Teknologi Bandung (ITB)

Project Leader: Prof. Dr. Soegijardo soegi@ieee.org

URL: http://biomed.ee.itb.ac.id

Amount and Duration: USD $ 26, 992 / 20 months

1. Project Background and Justification

1.1. ICT policy and infrastructure for Social and Community usage, with a case study in the Internet-based Telemedicine System for Primary Community Health-care in Indonesia - A social equity and sustainable communities issues:

In Indonesia, the primary health-care represents the basis of a very large health-care pyramid, and is formed by over 7,600 units of Puskesmas (primary community health-center) and their constituents, spread over the predominantly under-served urban and rural area which roughly covers more than 50% of the 202 million of the national population. Due to severe shortage of human-resources in the field of health-care in Indonesia, this primary health-care system operates on "referral-system" which, in turn, relies heavily on communication and transportation infrastructure.

Being a typical developing country, the physical-infrastructure development in Indonesia, especially in the field of communication and transportation, is one of the serious constraints affecting the efficiency of the national Primary Community Health-Care delivery.

Internet-based Telemedicine system, with its relatively low development and operating costs, may offer the opportunity of alleviating this system inefficiency. Lessons-learned from other developing countries indicated that even with the relatively low-cost internet-based system, such usage for social and community purposes would face problems in operations maintainability and sustainability.

It is proposed that with the appropriate but prudent "policy intervention" in the form of reform to the ICT policy and infrastructure, the internet usage for Social and Community purpose in developing-countries would become a viable proposition. The proposed research on this thesis will use the case study of an Internet-based Telemedicine System for Primary Community Health-care in Indonesia.

1.2. Practical solutions to the application of Internet-based Telemedicine System for Primary Community Health-care (social and community usage) in the under-served urban and rural-area in Indonesia based on the application of proven/ readily available Internet technologies and ICT Policy-Reform :

Our research laboratory had successfully developed a prototype of an Internet-based Telemedicine System for Primary Community Health-care for simple administrative and statistical health data-transfer in a well-developed Urban-area setting with commercial-line and subsidized funding which naturally had not yet addressed the issue of operations maintainability and sustainability in typically less-developed under-served urban and rural-area in Indonesia.
For this research, another prototype in the form of a Pilot network will be developed in some appointed under-served urban and rural areas to be used as the base of the above mentioned policy-research and to develop practical solutions to such implementation on a desired typically less-developed setting.

1.3. Practical solutions to the application and validity of simple but critical Clinical-data transfer through Internet-based Telemedicine System for Primary Community Health-care in Indonesia :

One primary criteria of a Telemedicine system is its ability to transfer Valid Clinical-data (i.e. textual medical information, physiological signals, clinical sounds, and medical images) from one point of referral to another. Considering the background of low-cost requirement, less-developed infrastructure and human-resource support, this Research and Development will focus its thesis on the Transfer-Validity of a selected Simple but Critical Clinical-data which will be required in the delivery of the Primary Community Health-care in Indonesia.
Based on the extremity of comparative health-statistics within the Asean region, the proposed focus Clinical-data will be related to the high MMR (Maternal Mortality Rate) in Indonesia; the ultimate goal of these activities will be in decreasing the Maternal Mortality Rate.

2. Project objectives

The objectives of the project are:

2.1. Develop a Recommendation to Reform the ICT Policy in Indonesia, specifically on the Social-equities and Communities-sustainability on the use of internet networking for Social and Community aplication, with emphasis on health related activities. Such recommendation might also include recommendations on infrastructure reform. The recommendations will be targeted to provide relevant input to two (2) currently drafted related-regulations in Indonesia, i.e.: (1). Draft of Presidential-decree on "E-Government" (status - 1st draft to be tabled by end of 2002), and (2). Draft Decree of Minister of Transportation/Communications on "Contributions for the USO/ Universal Service Obligations" (status - 1st draft circulated in late 2001), which will require further elaborations prior to its expected ratification in 2004; and thereby provide Practical-assistance (as different to theoretical assistance and input) through the below-mentioned Pilot-projects in establishing a sustainable platform for the Social and Community usage of internet-network in Indonesia.

2.2. Develop, implement, install & conduct a trial run of 6 Puskesmas medical stations in selected under-served and rural areas in Indonesia as a base for establishing a Pilot network of Primary Community Health Center (Puskesmas) internet-based Telemedicine

2.3. Establish a Pilot network of Primary Community Health Center (Puskesmas) internet-based Telemedicine consisting of 6 Puskesmas stations, 1 health office and 1 referral hospital in selected under-served urban and rural areas in Bandung/its suburbs, as a base for establishing a Pilot network of Primary Community Health Center (Puskesmas) internet-based Telemedicine Indonesia. The system will be used as a case study in preparing the above-mentioned ICT policy recommendation, and proving the validity of usage of the above mentioned Internet-based Puskesmas Telemedicine for selected Simple but Critical Clinical-data transfer.It is also expected that the system will be able to deliver trial integrated-package of "grass-root" telemedicine services, including limited teleconsultation, simple telediagnostic, telecoordination and tele-education. This will thereby provide a workable model of Telemedicine which is representative of the actual need in the field.

2.4. Implementing a pilot Digital Healthcare Infrastructure on available internet technology by linking all major components of the Primary Community Health-care delivery system (Community Health Centers, Referral Health Office, Referral Hospital, etc) and thereby strengthening the Health Referral system which had been hampered by insufficient infrastructure.

2.5. Enhancing day-to-day Primary Community health-care delivery, especially for the critically under-served Mother-Child health-care in Primary Community Health Centers through the application of Internet-based Telemedicine for Primary

2.6. Community Health-care ; and thereby assist in decreasing the MMR (Maternal Mortality Rate) in Indonesia.

3. Project beneficiaries

3.1. Potential users of internet for Social and Community purpose in Indonesia, especially for the beneficiaries of the Telemedicine for Primary Community Health-care

3.2. Under-served communities in the rural and urban area especially the critically under-served Mother and Child grouping.

3.3. All the major players in the delivery of the Primary Community Health-care in Indonesia, i.e. : Related Health-care provider; Primary Community Health Centers (Puskesmas), Referral Health offices, Referral hospitals.

4. Project sustainability

4.1. As the telemedicine system will support and enhance day-to-day activities of the Puskesmas, the operational cost are automatically covered by the existing health care system.

4.2. The future ratification of the above mentioned ICT Policy addressing the Social and Community usage of Internet (i.e. the Presidential Decree on "E-Government" and the Decree of Ministry of Communication on "Contributions for the USO/Universal Services Obligations") should provide operational-costing range which are maintainable and sustainable, even to those Puskesmas in the stated under-served area.

4.3. Training module for the users in the referral-nodes should enable the users trained under this Pilot project to become trainers to new and subsidiary users to sustain the operational continuity.

4.4. After proper dissemination activities (through seminars, meetings, mailing-lists, websites), it is expected that more and more Community Health Centres will provide medical stations on their own financial support.

5. Project methodology

5.1. Practical Research on Policy matters affecting Internet networking for Social and Community usage in Indonesia (with potential application in the Asia Pacific region) by using the practical input from concurrent development of the below mentioned Telemedicine system; which shall include, but not be limited to the following methodologies:

a. Review, analyze and interact/consult with the originator of the existing and drafts regulation on Social and Community usage of Internet in Indonesia, with focus on the two (2) most relevant drafts regulation, i.e. :

• Draft Presidential Decree on "E-Government" (State Ministry of Communications Affair)
• Draft Ministerial Decree on "Contributions for USO/Universal Services Obligation (Minister of Transportation/Communication)

b. Comparative study of similar experience on regulations for Social and Community usage of Internet in some selected Asia Pacific countries (i.e. Malaysia, Singapore, Australia and USA's NECA/National Exchange Carriers Association).

c. Conduct and facilitate "common-interests" consultation among representatives of other potential Internet-users for Social and Community purposes in Indonesia, especially those with interest to be part of the future "E-Government" network, which shall include, but not be limited to the following bodies :

• The State-owned Postal Services Company, which are managing a similar Internet network covering all the under-served areas within the Indonesian archipelago, which practically overlaps with the Puskesmas localities.
• The state National Disaster Center and its related SAR (Search and Rescue) body which shares the common-interests in such internet use for Social and Community purposes, which may include the need of telemedicine to/from remote locations on such natural-disaster emergencies.
• Police and other security related bodies which shares such common interests, which may include the need of telemedicine to/from security-problem areas.

d. Design and develop an interactive model to feedback the practical feedback from the concurrent development of the below-mentioned field-experimental Community Telemedicine pilot network with all the above studies/ consultations to enable maximum synthesis of recommendations to the ICT Policy formulation/reform on the Internet use for Social and Community purpose in Indonesia.

5.2. Design and Development of a larger experimental Pilot network system of an Internet-based Telemedicine System for Primary Community Health-Care for the under-served areas, to be used as a Practical-input for the above mentioned ICT Policy Research for the Social and Community usage of Internet in Indonesia; which shall include, but not be limited to the following methodologies:

a. Redesign and develop a Generic Community Health Center Main software using free-wares based on the Existing Community Health Center main software, which currently still uses commercial software (Utilizing the Borland database engine, developed by using Delphi 5 and runs on Windows)

b. Design and develop customized Maternal Health-care Digital Record Module through PC-based physiological measurement modules and their patient-interface to improve the early detection and diagnosis of selected maternal pregnancy related problems and monitoring the pregnancy i.e.

i. PC-based Ultrasonic fetal heart-rate monitor
ii. PC-based Sphygmomanometer
iii. PC-based Electronic scale

c. Design and develop a trial integrated-package of "grass-root" telemedicine services to serve any actual needs in the field, including limited teleconsultation, simple telediagnostic, telecoordination , tele-education and other potential modes.

d. Evaluate the validity of "Clinical utility" of internet data-transfer of all the above Telemedicine-data.

e. Design and develop Training module for users of the proposed Telemedicine system, which shall include the training, management strategies and technical support needed for health-care provider to adopt and effectively use telemedicine services available through the available infrastructure.

Internet-based Telemedicine System Block Diagram

a. PC Specification
Processor : Intel Pentium III
Memory : 128 Mbytes
VGA card : 16 Mbytes
Monitor : SVGA
Casing : ATX Middle Tower
Hard Disk : 20 Gbytes
Modem : V90 external
Speaker : active
Security module specification : 8051-family micro-controller-based
Standard soundcard, microphone, keyboard, mouse, voltage regulator and CCD Camera

b. Software specification
Operating System : Unix (FreeBSD/Linux)
Main program : web based software
Web server : Apache
Database server : MySQL
Administration software : php/perl based software
Security software : C/C++ based software

6. Project time-line

Scheduled activities: The project is designed for 20 months.

7. Project outputs

• "White-paper" containing the Practical Recommendation for an ICT policy reform/formulation regarding the Social and Community usage of Internet in Indonesia, especially in the field of healthcare, which had been based on the pilot Telemedicine network as described below.
• A Generic Internet-based Telemedicine System for Primary Community Health-Care including hardware and software modules for day to day primary health-care in Community Health Center , which could form the impetus of a National Telemedicine system for Primary Community Health-care in Indonesia.
• Dissemination activities (through seminars, meetings, mailing-lists, websites) to promote the application of the ICT-based telemedicine systems. The Research Group on Biomedical Engineering ITB will freely offer the use of the systems that has been developed, to as many as possible number of Community Health Centers. Therefore, the number of users will be gradually increased even after the project has been completed; in other words, it is expected that sustainability of the activity will be achieved.

8. Project monitoring

8.1. Monitoring

• Regular Team Supervisions (meeting/discussion) every two weeks
• Coordination (coordinative team meeting) every month, and as necessary
• Periodic meeting with associated policy authorities

8.2. Evaluation

• Making sure that the project is progressing in accordance with the project timeline, and making adjustments as deemed necessary
• Technical design evaluation regarding the effectiveness of telemedicine system in enhancing maternal health-care delivery. This will be conducted by measuring some parameters before and after the implementation of PC-based telemedicine system
• Assessing the Clinical utility of the system
• Examine whether clinical observations by PC-based instrument (using telemedicine) are equivalent to in-person observations
• To evaluate the effectiveness of the telemedicine system for primary community health-care

View the Abstract of Project