Dr. P.S. Ramkumar
Cyber Security Division
International Telecommunication Union
1
Threshold
25% Less
Do not force-fit Technology Solutions
Match it with Demographic readiness
2
Information Communication Technology (ICT) adoption can help to
EXTEND FROM CURATIVE TO PREVENTIVE CARE,
EPISODIC TO CONTINUM OF CARE
REDUCE WASTAGE, COMPLEXITY, TRAVEL
AND MANUAL DOCUMENTATION
AGGREGATE DEMAND AND DISTRIBUTE SUPPLY ELECTRONICALLY,
LINK PATIENTS TO DISTANT HEALTH FACILITIES
COST
INTEGRATE WORKFLOW AND DATA FLOW LOOPING ACROSS
SURVEILLANCE, PLANNING, TRAINING, DEPLOYMENT
INNOVATE SERVICES BASED ON AVAILABLE INFRASTRUCTURE
3
Technology Platform should
accommodate
Indian Demography:
 Population 1.2 Billion, 70% rural
• Diversity (workflow, dataflow, linguistic,
economic)
 Nurses, doctors < 1/1000,
• Obsolescence (Technology, protocol,
policy)
 40% with 10 hours power
• Collaboration (Privacy, Security, loyalty)
 200 Million English speaking
• Interoperability (software, protocols,
devices, data formats)
 200 Million computer users
• Commerce (billing models, payment
methods, cash flow)
 DALY 200MLY
 Languages 22/1600,
cut/day,
 1.3 Billion mobile phones
• Usability (Literacy, Debilities, Language,
Context)
4
Challenges: Demographic readiness
ASPECT
LEVEL 1
LEVEL 2
LEVEL 3
LEVEL 4
LEVEL 5
Power supply
Unscheduled
cuts
Shceduled but
frequent cuts
Seasonal cuts / Genset
backup
Solar UPS/ GENSET back
up available 24X7
Hardly any power cuts
TeleCom
None
ISDN / PSTN
Satellite / Cable
DSL/ 2G wireless
OFC/ WIMAX/ 3G
Literacy
oral skills
Oral, Reading and
writing skills
ORW + electronic data
entry
Data processing and
reporting
Data analytics
Linguistics
Local Language
only
Regional
Multilingual
Regional and National
Regional, National and
International
Transcription/
Transliteration
Technical skill
Calculation
Operational
Servicing
Managerial skills
Organizational skills
Affordability
Rs 600
Less than 1.2K
Less than 12K
Less than 60K
100K+
Illness Cause
Hygiene and
malnutrition
Habitual disorders
Infectious / vector borne /
contagious
Preventable diseases
Geraitric,Lifestyle
management, Global
Commerce
Barter / Material
/ Crude Debt
Teller Cash
transactions
ATM based cash access
Cashless / TPA driven
models
Insurance based
automation
Automation
Basic manual
records
Electronic record
capture +access
Billing and Accounts
Automation
HIS/RIS/PACS/LIS
PHR, Community Blogs,
Tele-education / care
portals, etc
Accessibility
Information
center
Primary health
center
Secondary health center
Tertiary care
Home care (chronic)
Staff
Health worker
Nurses/paramedic
GP’s, Pathologists
Specialists, Surgeons
Departmentalized services
Funding
Self funded
Govt.
WHO,UNICEF,NGOs.
Community Insurance
Private Insurance
Disaster
preparedness
Based on
Census
Seasonal
correlation
Continuous
Environmental monitoring
Emergency management,
daily monitoring
Forecasting and Multi site
coordination
Transportation
Crude /self
owned
Private service
Govt. transport
ambulance
Helipad ambulance
Inventory
First aid
Containment
Centralized response
Decentralized Nodal tree
Research facilities
Infrastructure
Counseling trip
Bio-chem/therapy
Radio/Cardio LABs
Multi-speciallty Hospitals
Multi-Hospital Networks
5
Challenges Sustainability:
Consumable
spend of $500M
per year
Takes about 8 Y
to break even on
investment
Glucometer ~ $100 + $0.5
consumable
Usage density 
BP ~ $100
PC based ECG
Asthma (peak flow meter) ~
$30
~$2.5K
Capnography /Oximeters
~$3K
Ophthalmoscope ~ $1.4K
Cholesterol / lipid
test~$500
Spirometer ~$2K
Stress test ~$5K
EEG/EMG - $5K
Ultrasound dopplers
~$50K
Audiometer ~ $3K
Holters ~$12K
Automatic Defib ~2K
Video EEG ~ $40K
Motorized Wheel
Chairs ~ $2K
Coagulation tester ~ $1.1 K
Bone Densitometer ~
$10K
Patient Lifters ~$4K
Antepartum monitor ~ $3.8K
Otoscope ~$ 600
$Ks
Vascular Doppler - $2K
10s of K
BIO-Chemical Analysis
~ $150K
$100Ks
CT - $500K
Radiology (MRI) ~ $1.5M
CATHLAB - $300K
$Ms
COST
6
Challenges: complexity
Example: operating skill
Analysis
Server
Patient end
device
Storage
server
Push processing and storage
to back end S/W implementation
Distributed
Device
Network
Reduce cost and complexity at
Patient end device
UI Server
Monitoring
Server
Aggregate traffic from multiple
devices and patients on each
functionality server
Transition pay per device to
pay per use
7
CHALLENGES : INTEGRATION
Pharmacy
Clinic
Legal
Training
PHARMA Nursing
Clinic
PHARMA
Ambulance
Transport
Massage
TPAs
Clinic
Safety
monitoring
Clinic
Concierge
Patient
House
maintenance
Therapy
CALL
CENTER Insurance
Laundry
Clinic
PHARMA
LAB
TC
Legal
Security
services
Clinic
PHARMA
Pharmacy
Catering
Clinic
Telecom
Provider
LAB
Clinic
Ambulance
Hygiene
Support
HOSPITAL
PHARMA
Therapy
Catering
LAB
Ambulance
Telecom
Provider
Commodity
Supplier
Therapy
Massage
Laundry
PHARMA
Agency
HOSPITAL
Nursing
agency
Clinic
Transport
PHARMA
HOSPITAL
Insurance
Nursing
agency
Banking
8
Layering of information exchange across Health care process
Survey Health care initiatives and identify care activities (6)
Identify possible transactions within such activities (35)
Categorize nature of information exchange events within transactions
Map user platform & communication requirements for information
events
Group information events with similar requirements in various
transactions
Remap and group information events as a function of infrastructure
9
Distribution of information data-type within transactions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
video
Audio
Image
Signal waveform
Text
10
Distribution of information data-size within transactions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
>100Mbytes-Extremelylarge (E)
0%
< 160 Bytes- Tiny (T)
<32Kbytes - Small(S)
<1Mbytes – Medium(M)
<10Mbytes Large (L)
<100Mbytes - Very large (V)
> 100MBytes – Extremely large
extremely large
very large
large
medium
small
tiny
11
Nature of information access latency within transactions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Real-time
Store & Forward
12
Distribution of need for data agility within transactions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Stationary
Portable
Mobile
13
Computation and communication load mapping
Desktop – D, Laptop- L, Text based Cell Phone – C, Smart Phone – S, Dedicated Equipment – E, Land Line Telephone- T
Activities
Transactions
Type of Information exchanged in the transaction
Data
type
T
Data
Size
S
Transfer Mobility Link
User
mode
type
Platform
S
M
TSMLE DCSL
S
M
S
P
TSMLE LDS
TS
S
S
P
TSMLE SCD
T
L
S
P
SMLE
D
I
L
S
P
SMLE
D
P
SMLE
DL
P
SMLE
DL
Endoscope,
V 𝐴𝐴𝐴𝐴
L
P
SMLE
𝑁𝑁 𝑡 = �
𝑊 𝑘,otoscope,
𝑡 ; dermoscope
𝑁𝑁 𝑡 = � 𝑊 𝑘, 𝑡 𝑎𝑎𝑎
=S 𝑁𝑁(𝑡)/𝑁𝑁(𝑡)
DL
Surveillance Register
(citizen details)
citizen
for
screening
Conduct
(ECG /PFT)
Screening
(HR /BP/Temperature/weight/etc)
tests
Biochemistry lab report
Microbiology images
𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝑓𝑓𝑓𝑓𝑓𝑓𝑓𝑓
𝑜𝑜 𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖
𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 (AFIX) AT
estimation
Heart Sound,
audiogram
M
S
𝑘=𝑥
Ophthalmology tests
𝑘=𝑦
𝑘=1
𝑘=1
Screening reports
Care
program
management
M
S
T
M
S
P
TSMLE DL
T
S
S
P
TSMLE DSC
( regional, seasonal and sporadic disease incidence, morbidity- T
mortality reports etc)
S
S
S
TSMLE DL
(Hygiene, pollution levels in air/water/food, industrial efflux, T
pests, insects, climatic change, etc.)
( known/unknown symptoms of genetic disorders ,ethnic TI
predisposition, habitual disorders, etc in target population)
T
S
S
TSMLE DE
SM
S
P
TSMLE DL
M
S
P
TSMLE DL
M
S
S
TSMLE D
M
S
S
TSMLE D
Lifestyle issues
Trending
of
health
indicators
Environment
monitoring
Genetic
and
habitual risk
profile
Care program
planning
IV
(Surveillance trend reports, target prioritization, pert-charts, T
resource scheduling and booking forms, inventory ordering,
supply chain configuration, etc)
Care Network Registration/authorization/suspension/termination forms for T
entities
care entities and care personnel.
management B2B SLAs, contracts , MIS and Audit configuration forms, T
status upload forms
14
Transaction and information exchange coverage in various user
platforms
110%
Land-Line
Phone
100%
90%
Basic Text based
Cell Phone
Transaction coverage
80%
70%
60%
Smart Phone
50%
40%
Laptop
30%
20%
Desktop
10%
0%
100%
>75%
>50%
>25%
information exchange event coverage
<25%
Dedicated
Equipment
15
Transaction and information exchange coverage for various connectivity
standards
120%
ISDN/
DSL/
EDGE
(<256Kbps)
100%
Transaction coverage
CDMA2000/
GPRS/
PSTN (
<64Kbps)
80%
VSAT/
HDSL/
XWIFI
(<1Mbps)
60%
40%
VDSL/
CABLE/
EV-DO
(<10Mbps)
20%
0%
100%
>75%
>50%
>25%
<25%
OFC/
WIMAX/
HSDPA/ LTE
(<100 Mbps)
information exchange event coverage
16
17
18
Layered Architecture of ICT for Health Care Process
Focus
Functionality
Specialties
Managed
Program
Disease surveillance and control, Chronic
disease management, Lifestyle / fitness
management, Chronic Disease
management, Public health and hygiene,
infection control, de-addiction, etc.
Diabetes, Arthritis, CVDs, pre-post natal
care, pediatric care, geriatric care, public
hygiene surveillance, obesity
management, Asthma, Cancer, Mental
diseases, infertility, etc.
Managed
Services
Consultation, Screening, Diagnostics, and
Reporting Treatment ,diet / exercise/ Vital
sign/ health Monitoring, hygiene / physical
support, safety and security, Training
,Rehab, legal support, etc.
Ophthalmology, Radiology, Pulmonary,
Cardiology, Orthopedic, OB/GYN,
psychiatry, Radio/ physiotherapy,
Neurology, Nephrology, Dental, ENT,
Endocrinology, Dermatology, etc.
Managed
Logistics
Resourcing, work allocation, scheduling
and tracking, transaction metering, billing
and collection, fleet management,
Advertisement, inventory , travel and
information support,Translator,etc.
Hospital, clinic, Pharmacies, Ambulance
and Transport agencies, Security
agencies, Banks, Insurance-TPA, Legal
support, Nursing agencies, Saloons,
Catering agencies, marketing agencies,
call centers, etc.
Managed
Dataflow
and
workflow
Multi-media (Text/Audio/Video/
Image/Touch/ Type/ Scan/ Waveform)
acquisition /compression/ validation/
storage /security /processing /distribution
/presentation/etc. CRUD/verify/ Analyze/
Track/ alert/ Publish/Visualize
Bio-medical systems, payment gateway,
appliance control, environment sensing,
video conferencing, multi-media data
capture, multi modal access control ,
UI/Document / Workflow configuration
engines, messaging gateway, etc.
19
Virtualize service networks
MOBILE WEB
TERMINALS
(HTML5 /
JAVASCRIPT
BROWSER
BASED DOM
CLIENTS)
ENTERPRISE
TERMINALS
(ASP.NET/PHP
/CITRIX/etc.
CLIENTS)
VIRTUALIZED
ENTERPRISE
WORKFLOW
USING
JAVA / .NET
BASED
WEB
SERVICES
ENTERPRISE
SERVER
ENTERPRISE
SAN DATA
STORAGE
WITH
BIGDATA
INTERFACES
CLOUD
GPRS/3G
GATEWAYS
(ZIGBEE/WIFI
BASED HOME
AUTOMATION
20
NETWORKS)
Tele-Training
21
Prescription
1
Medication Tracking
23
Digital fencing
Tele-Consultation
Tele-reporting
Tele-Documentation
24
Automatic detection
Programmable bounds
Complete information
Does not require SMS, direct notification
Videoconferencing with patient and doctor
CASE STUDY 1 : Real-Time Bio-Surveillance Training Program: Directorate of Public
Health and Preventive Medicine, Tamil Nadu, India
Effect:
• 3 months to 1 day detection and response, coverage to 60000 people, in 4 months
• employment to less educated villagers, age 45, with just 2 week training
• direct interaction, using $20 2G mobile device,
26
CASE STUDY-2 Sustainable Tele-Health Network for preventive and curative
interventions – World Health Partners, Uttar Pradesh, India
Effect:
Networked 1800 pharmacies, 128 villages, 1200 health workers, 9 labs, 14 urban hospitals
Avoid unnecessary travel and logistic expense
Free Logistic and information support at each village
27
Remote screening and escalation of deserving cases, follow up after discharge
CASE STUDY-3 Urban Tele-Health network - Ojus Health Care, Bangalore, India
Effect:
• Care extended to corporate offices and campuses
• Avoided unnecessary travel in traffic jams and stress
• Annual Membership $100 including package of consultation,
regular medicine delivery, bio-sample collection at tele-clinics
Figure . Ojus preventive and
palliative care Network facility
(Courtesy: Ojus health care)
28
CASE STUDY-4 Disaster management and Proactive care in Tele-Health Network –
Amrita Institute of Medical Sciences(AIMS), Kerala, India
Remote echocardiography,
colonoscopy, retinal camera,
ultrasonography, X-ray
radiography, electrocardiography,
biochemical analysis, light
microscopy, photography;
videoconferencing capability
(adopting H.264 and G.711
compression, H.323/SIP protocol);
extended C band satellite
Effect:
60 hospitals, remote difficult terrains, distant sites covered connectivity(min 384 Kbps)
Employment generation reducing skill levels
24 X 7 support for disaster situations
29
CASE STUDY – 5 : Private sector Tele-Consultation network - Apollo Hospitals , India
30
CASE STUDY-3 Remote Continued Medical Education (CME) network - Sanjay Gandhi
Post Graduate Institute of Medical Sciences(SGPGIMS), Lucknow, India
Effect:
• Access to larger pool of human resource for simultaneously training
• Reduced travel and logistics for students
• Rapid learning interaction with multiple remote experts
31
Ongoing Work: Elder Care Exchange
150 Million Population is above the age of 65
CHALLENGES GROW WITH AGE ….
Memory : person/place/thing/tasks(gas)/pathways/location(switch),etc.
Mobility : cannot move/lift/bend/wear/operate/hold/reach things.
Agility : loss of logic, mixing up options, tasks(diet/medicine/ exercises)
Interaction :Poor hearing, eyesight, touch, smell, speech, signature, etc.
Chronic: need regular consultation/tests/treatment/diet /medication
Psychological: lonely/depressed/addicted/anxious/impatient/inferiority.
Hygiene: bathing/brushing/shaving/toileting/laundry/cleaning/cooking
2013
2013
1998
Transaction: Going to grocery shops, pharmacies, restaurants, banks.
Copyright of Applied Cognition Systems Pvt. Ltd., Bangalore, India
www.apcogsys.com
32
Comprehensive Care Coordination is a Central, Neutral missing Role
Copyright of Applied Cognition Systems Pvt. Ltd., Bangalore, India www.apcogsys.com
33
Activity
Disease
Arthritis
Diabetes
Health monitoring – Routine measurement (BP/O2/HR/ heart-sound/RR/ Arrhythmia /
Glucose/ Temp, weight, urine/stool/sputum discharge), with auto-trending, anomaly
detection and alerting
Consultation –video conferencing with doctor for medical advice and counselling,
prescription and referral, training and group discussions, legal consultation.
Care management–schedule, prompt, track medication /diet/exercise compliance
Emergency handling –escalation first-aid video, ambulance and hospital booking
Treatment – Schedule and track wound management, medication, therapy, Rehab.
Commerce - Ordering, billing, collection, distribution, delivery tracking
Mobility management – motorized wheel chair, table, patient lifter, cabinet, etc.
Self-reliance – Mobile patient console for appliance controls (proximity, floor plan,
schedule based), Signaling (hunger/pain/toileting /emergency /fear, etc.) and Rehab(hand
writing , word, object, color and speech recognition)
Memory loss – Reminder with video walk-through, Self-Rehab tools, object locating/
digital fencing, guidance for activities and path tracing to/within home
Safety – Access control(Schedule, biometric, keyword, video chat based), motion sensing,
video surveillance, gas leak, water overflow and fire detection and control.
Hygiene management – Routine scheduling, ordering, tracking and reporting
Appointment- Equipment, staff, facility booking (home/office/OPD) and tracking
Citizen care record (CCR) –Multi-modal data entry (speech, typing, writing, video,
image) for documentation, comments along with digitization, of old medical records
34
Мнения доктора К.С. Гопинатха (Хирургический онколог)
Doctor K.S. Gopinath’s comment
35
Мнения профессора Кишор Падке
ProfessorKishore Phadke’s comment
36
Further Reading:
https://www.itu.int/ITU-D/cyb/app/docs/Tele-Health%20in%20India-e_final.pdf
(Landscape of Tele-Health infrastructure at points-of-service in India )
https://www.itu.int/ITU-D/cyb/app/docs/Scaling%20e-Health-E.pdf
Scaling e-Health Services in step with ICT transformation
Спасибо за внимание!
Thank you!
psramkumar2@gmail.com
Dr.P.S.Ramkumar
Expert, Cyber Security Division
International Telecommunication Union
37