Project Proposal

1. Project background and justification

In general, Telemedicine can be defined as the delivery of health care and sharing of medical knowledge over a distance using telecommunication means. Telemedicine provides medical information exchange at a distance, to support medical procedure, with the ultimate goal for improving community health care. The aims of telemedicine is also to provide expert-based health care to understaffed remote side and to provide advanced emergency care through modern telecommunication and information technology. Information technology has been confirmed as an effective and efficient tools for delivering health services to widely distributed population such as Indonesia.

Under the full supports of the Asian Media Information & Communication Centre (AMIC), the International Development Research Centre (IDRC), Pan Asia Networking, Asia-Pacific Development Program (APDIP), and the Asia-Pacific Network Information Centre (APNIC), since November 2002, we have been developing Internet based telemedicine system. The system has been focused on primary Community Health Care with the aim for reducing Maternity Mortality Rate (MMR). At present, the system has been operated and continuously being self-developed, by Bandung Health Office and more and more Community Health Centres in Bandung. Unfortunately the existing system covers relatively small number of Community Health Centres (CHCs, Puskesmas). Since Indonesia has more than 7600 (seven thousand and six hundred) Community Health Centres to serve more than half of the total Indonesian population, therefore the existing telemedicine system is far from enough, compared to the whole national requirement.

The developed system operation mostly relies on existing public communication infrastructure, i.e. fixed public phone. The problems with a non-mobile telemedicine system are:

• It is not easy to be developed and less flexible, particularly in areas where the communication and transportation infrastructure has not been available yet.
• Deployment of the system could be very problematic especially in case of emergency cases/natural disaster such as tsunami, earth quake, and flooding as just happened in Aceh, and Nabire.
• Indonesia has more than 220 millions population, spread out all over the country. Because of the demography condition of Indonesia, a mobile and/or movable system will be demanding because a fixed system is difficult to be reached by patient living in remote urban or rural area, so he or she can not be given proper health services.

In order to alleviate these problems and support different growing application of telemedicine, this project proposes the Development of ICT-Based Mobile Telemedicine Systems with Multi Communication Link. One of the crucial problem to deliver health services in Indonesia is the specific demography, and the availability of needed infrastructure. The proposed system will exploit the advantage of wireless technology and combine it with other communication technologies such as wide band radio packet to satisfy different locals and demographic requirements.

2. Project objectives

2.1. Develop an ICT-based mobile telemedicine system that can be functioned as an emergency health care unit for urban and rural area. The system consists of 2 (two) major parts. Firstly is a Telemedicine unit that may be portable (easily movable) and located at the patient’s site; and secondly is a base unit or doctor’s unit located in a medical monitoring centre/referral hospital. Communication between the two units can be established using wireless digital cellular, radio packet or ordinary fixed telephone lines.

2.2. Improve and enhance the health care services to people in urban and rural area, especially for medical consultations and medical care for patients who live far from city areas.

2.3. Establish a pilot project of application wireless local area network in pre hospital environment for capturing data by using PDA, laptops, and cellular phones. The captured data will then be transmitted to a physician or nearest hospital.

2.4. Improve management of medical resources particularly in rural and underserved areas by using these technologies, so patients who are in a remote location may still have access to medical expert opinion.

3. Project beneficiaries

3.1. Patients who live in rural area or far from hospital could be given a routine check up by using mobile phone. In addition, severely injured patients can be managed locally and access to medical specialist accessed by wireless telemedicine, hence the system may provide fast response to critical medical care in spite of geographic barriers.

3.2. Local hospitals usually they do not have enough medical expert and nursing staff who are able to manage seriously ill patient. By using these technologies, this such kind of problems may be alleviated.

3.3. Local authority, since this project can support a program for reducing Maternal Mortality Rate (MMR) and improving Mother and Child Health which has to be served by local authority.

4. Project Sustainability

ICT-Based Mobile Telemedicine System with Multi Communication Links is obviously one of the best solutions to overcome various national health problems in Indonesia, since the system offers flexibility for development that suit to a condition of local needs. In addition, by applying the system, it is possible to build an integrated system disease management in order to provide a quality health care at affordable costs. With so many advantages of the system, it will be a reasonable choice for the government to put the sustainability of project as a priority of its national health care development agenda.

The finance for the sustainability of the project has to be included in State Annual Budgeting Planning - RAPBN in order to guarantee equal access to medical services to all citizens regardless of the location of their residence. Moreover, there should be adequate fund from government and privates / community to support researches in this area involved multidiscipline and multipartite.

5. Project methodology

The scope of this project is to develop and implement an integrated telemedicine system that can manage different telemedicine requirements in Indonesia, Integrated telemedicine system means the system is able to serve different requirement of telemedicine, for instances information dissemination and health education, patient data acquisition, emergency health care condition in any inaccessible located health centre, or rural hospital, and home telecare for patients suffering from chronic and/or enduring diseases.

The system can be operated in both on-line mode and the indirect mode (data is stored and forwarded later on). The data can be transmitted in different mode of communication links, and the system will be ‘bandwidth independent’. As a result, the system should be able to be employed effectively even if only the lowest bandwidth is available in the local area. To achieve this objective, the system will be provided with options of variety communication links from ordinary telephone lines, mobile telephone both GSM and CDMA, and packet radio. Depending on the geographic location, a user can determine the mode of communication that suits his or her requirement.

The following methodologies will be carried out to implement the project :

a. Assessing the available communication means within the area of interest. For the time being, the area to be explored is Sukabumi – West Java with the reference hospital is Bunut Hospital.
b. Doing a comparative study to selected Asia Pacific countries, i.e. India, Australia, to learn from their experience in developing a mobile telemedicine system
c. Developing the hardware and software communication interface module to perform voice, data transaction and video for telemedicine purposes
d. Developing the hardware and software platform for telemedicine including the telemedicine data base
e. Integration of the developed modules into the telemedicine system
f. Identify the information and service needed by the doctor side including the medical data base
g. Development of the required hardware and software platform for the doctor site
h. Field test of the telemedicine system, analysis, and reporting.

The most important aspect to be considered is the real application of the system which will define feasibility of technical constraints.

Mobile telemedicine directs a mobility aspect of patient, medical data , health services, and emergency team mobility. The system is based on the deployment of a mobile unit provided with computer, and diagnostic devices and processes. The unit is called Telemedicine (mobile/movable) unit, and supported by specially designed hardware and software. To match the Telemedicine Mobile Unit, the project will also develop a Base unit or Doctor unit that is placed in Medical centres or any reference hospital.

According to the most needed requirement of health services in Indonesia, the design system will be focused on application telemedicine for:

• Tele diagnostics 
• Tele consultation 
• Recording and reporting 
• Distance education 
• Other service applications.

A proposed system of the Mobile Telemedicine Unit is depicted in Figure 1, while Figure 2 describes a Hospital or Doctor unit.

5.1.1. The Mobile Telemedicine Unit

Basically the Mobile Telemedicine Unit consist of three blocks i.e. the medical devices that performs measurement and acquisition of medical data/information including a set of video camera equipment; the communication block , and a processing data unit.

Figure 1: Mobile Telemedicine Unit

Medical devices block

Medical devices which are equipped in the unit may vary, according to the urgent medical services that mostly demanded by the community within the area of interest. Each of medical devices is connected to a Telemedicine Arbiter that functions as an interface between the equipments and the local PC. Moreover, the telemedicine arbiter is also applied as a control unit for communication transaction to local PC and the communication manager.

Communication block

The communication block consists of two main parts, namely:

• Telemedicine Arbiter 
• Communication manager.

The arbiter is responsible for data acquisition and or polling of medical record from various medical devices. Data will be saved in a Medical Data Base. One of the most important factor has to be taken into account is the possibility of serving wide range of data format. A special purpose software must be designed as a protocol for data exchange, and biosignals acquisition modules to support the required system has to be developed as well.

Communication between the Mobile Telemedicine Unit and the Hospital Unit is implemented by using different communication mode. In order to carry this task, a communication module, viz. Communication Manager will be designed. This module provides an option for data transmitting according to the available communication link infrastructure, and consists of multi modem (radio, GSM, CDMA, Fibre optic). Operation of the module will be controlled by predefined software communication protocol to manage data transaction (data flow in – data flow out) that matches to format data based on available communication link, determine a kind of communication link, and maintain connection between the Units.

Processing Data Unit

A personal computer is used as a processing data unit. The selection of the computer depends on the application of the Telemedicine Unit, i.e. connection parameters to a high speed computer network that translate different data format ( patient record, image, multimedia), efficient storage of data, and effective handling of growing number of system and user.

5.1.2. The Hospital Unit

As shown in Figure 2, the Hospital Unit consists of a dedicated PC and a Communication Manager. The PC is used for monitoring signals and data coming from the Telemedicine Unit. Incoming signals are biosignals measured by medical devices within the Telemedicine Unit. Data may be in a various format, and the data transaction is controlled by the Communication Manager.

Figure 2: Hospital / Doctor Unit

5.2 . System design and technical implementation

Mobile Telemedicine Unit is created to be expandable and flexible according to the user requirements. Hence, the unit is designed in modular form, The mobile telemedicine unit will be provided with both hardware and software. The minimum hardware contains a PC or laptop, a digital camera, power source, and medical devices. Based on the most needed requirement, the medical devices included are:

1. Blood Pressure 
2. ECG machine 
3. Doppler Fetal monitor.

It is desirable to use only digital instrument and medical devices, although analog instrument may also be used if needed. The main consideration which must be taken into account are the accuracy level of biosignal and data required by doctor for diagnosis, portability, and robustness means the devices can operate in almost any circumstances area. In addition, the mobile unit will also be provided with image processing software and a scanner for digitizing resulted image.

This system contains also Patient Information Record (PIR) that is needed for providing health care using telemedicine. The medical information consists of clinical as well as non clinical data. Clinical information is health information of a patient, viz.:

• the illness he or she is suffering for
• the physician’s observation of the patient’s illness
• the diagnostic test to be carried out to determine the patient illness 
• the result of the diagnostic test 
• the kind of treatment to be given 
• the method of treatment should be given to him or her.

Moreover, the non-clinical information is about the patient’s environment, such as address, occupation, spouse, age, etc.

The telemedicine system will be designed to be used in a hospital / CHC – Puskesmas, or in a mobile place. Depending on the application and space constraint, the platform of H/W and S/W for telemedicine system may vary. For this project, the hardware platform is determined as follows:

Hardware

a. PC specification

• Intel Pentium-IV, 2.4 GHz with appropriate mother board 
• Appropriate number of Serial, parallel & USB ports 
• Interface for Digital camera 
• 40 GB (minimum) or more HDD 
• 1,44 MB FDD 
• 256 MB DD RAM, up-gradable to 1 GB 
• High-resolution colour monitor for displaying medical data/images.

b. Laptop specification

Processor Intel Centrino is prefer, and other specification of a laptop PC are similar to the desktop PC.

c. Power source

The power requirements for computer, and other medical devices are common, i.e. 220 volt, 50 Hz. In addition, a number of equipments must be provided with appropriate batteries.

d. Printer

Any appropriate standard printer for high quality printing

Digital camera system provided with resolution at least 2.1 mega pixel or better, with minimum illumination of 5 lux, with an interface to the computer.

Medical Equipment

As mentioned earlier required minimum configuration for telemedicine diagnostic equipment in Indonesia are as follows :

a. Digital ECG
Specifications :

• Leads : standard 12 leads 
• Freq. response : 0.5 – 125 Hz, or better 
• Leakage current : < 10 Micro amps 
• Input impedance : > 20 M Ohms

b. Fetal Heart Rate Monitor
Specification :

• Technique : Continuous Doppler with Auto Correlation 
• Frequency : 2.5 MHz 
• Range : 0 – 100 units 
• Bandwidth : 0 – 0.2 Hz

c. Blood Pressure

Any appropriate standard.

• Software

To implement the mobile telemedicine system, a dedicated software will be developed. The software should be able to perform the functions as follows:

• acquisition of patient related information 
• store of the patient information 
• display of patient information 
• transmit the information over a communication link 
• scheduling of doctor appointments 
• capture image / document from scanner 
• capture of video / other data from the output out the medical equipment .

The software specification

• Operating System : Under Window Xp
• Nain program : Delphi + VB 
• Web server : Apache 
• Data base server : MySQL 
• Security software : Firewall, anti Virus, C/C++ based software 
• Communication s/w : TCP/IP

The expected system is a low cost and easy to deploy solution hence during the development the system the use of low cost and general purpose components will be suggested.

6. Project time-line

The project is designed to be implemented within 24 months.

As described earlier that the objectives of the project is to develop an ICT-based mobile telemedicine system with multi communication links. The project would deliver a working user tested ICT-based mobile telemedicine system that support community health services. Also the project will produce report and recommendation of the application of telemedicine infrastructure for rural community.

8. Project monitoring

Monitoring

Monitoring is carried out in order to maintain the project milestones meet to the project time-line. Monitoring will be done as follows:

• Regular team supervisions (meeting/discussion) every week 
• Set up project log book for each team member 
• Coordination (coordinative team meeting) every two weeks, and as necessary 
• Periodic meeting with associated policy authorities 
• Periodic progress report every month.

Project evaluation will be conducted based on technical performance, clinical evaluation and user survey.

A. Technical performance

Technical performance evaluation consists of parameters, such as:

• Technology applied selection, concerning to compatibility, scalability, interoperability, and reliability of equipment and systems used that meet these requirements 
• System design regarding to low-cost, high coverage, and secure data transmission. This system will be implemented over public wireless phone networks . On the other hand, sending a video and data stream through low bandwidth and low reliability media is another technical challenge which has to be overcome instead of connectivity and quality of service.

B. Clinical evaluation

Clinical evaluation of the system will be implemented on the subject of the accuracy of the diagnosis which depends on the quality of transmitting data whether bio signals or images.

C. User survey

To gather data and/or opinion of the users of the mobile telemedicine, a questionnaire will be designed which covers areas concerned, i.e. (1) data security, (2) usability, (3) effectiveness, (4) interference.