Medical informatics and telemedicine: Application in clinical practice
Dr B D Gupta

Considered as an offshoot of information technology, Medical Informatics is, in fact, the conglomerate of information technology and the different disciplines of medicine and healthcare. Medical Informatics has multidisciplinary characteristics as that of medical sciences which include the clinical disciplines and healthcare. The new term of Medical Informatics dates from the second half of the 1970s and was borrowed from the French expression Informatique Medicale.

Earlier, there were several names used and are still in use, namely Medical Computer Science, Medical Information Science, Computer in Medicine, Health Informatics, etc. There are many more specialised terms used for other disciplines of medicine such as Dental Informatics, Nursing Informatics and so on. In common terminology, informatics has many special areas and different attachments and manifestations which can be described in the following terminology:
1. Fundamental computer science
2. Application-oriented informatics and, lastly
3. Applied Informatics.

The medical information system mainly belongs to the second and third categories. In clinical practice we deal with medicine and healthcare as a whole and it is a combined effort of medical specialists and scientists coming from different disciplines especially computer science and software engineers who develop tools for application-oriented programmes in conventional and specialised areas.

Medical Information can be better defined as the development and assessment methods and systems for acquisition, processing and interpretation of patient data with the help of knowledge that is obtained in scientific development using computers and software technology. In fact, computers are the vehicles used to achieve these goals in clinical medicine and in medical informatics we deal with entire domain of medicine and healthcare from computer-based patient records to image processing and from primary care practice to hospitals and regions of healthcare.

Informatics after being developed as medical informatics further proved to be of help considering that the systems already developed and made operational for one medical speciality can be used or transferred to other specialities easily and the same tools can be used.

The development and procedures thus acquired in the form of theoretical and practical application for information processing can be communicated through the available channels (such as telephone, ISDN lines, etc) and this then becomes telemedicine technology. In clinical practice there are three stages which play a key role in patient care, management and also research. The patient describes or tells his/her history of illness. The physician or clinician collects the data during physical examination, by laboratory tests, by radiology and other diagnostic procedures and finally comes to a conclusion and makes a diagnosis. Thereafter, he/she prescribes treatment and/or carries out some form of treatment as applicable to the patient’s diagnosis thus arrived at. We must understand that this is essential for medical profession to know that in collecting data we are often faced with considerable anomalies as incomplete or incorrect answers from the patient — Noise on biosignals (ECG recording and like many others) or errors in biomedical analysis and interpretation of images of radiology, pathology, cytology, etc. In many cases we may not be able to obtain the data in which we are interested because the organ or the region of interest cannot be reached by non-invasive procedures. In specific situations the physician or the surgeon may have to decide to proceed through invasive procedures in order to collect additional patient data and therefore have to carry out exploratory examinations such as catheter insertion and endoscopy or laparoscopy or by obtaining a specimen by performing a biopsy.

It is, therefore, a challenge in medical informatics to assist in interpreting data that are required from the patient. By using patient data thus acquired by clinical and physical examination and using different methods and techniques, it is really a task of medical informatics to support the clinician in collecting necessary data and providing decision support methods so that the diagnosis can be derived in an efficient manner while maintaining quality of care and at the same time decreasing the inconvenience to the patients as much as possible. Once a firm diagnosis is made, treatment becomes simple and therapeutic planning can be made.

Finally, the goal of all information processing is, of course, the achievement for accurate diagnosis and the right line of treatment with greater speed without losing precious time to save lives. The computer application and software tools certainly play an important role in decision-making to the last stage of the diagnosis. We can cite several examples: (1) data in computer-based patient records. If they are coded, can be used for decision support, (2) in radiotherapy, the radiation equipment is automatically adjusted and calibrated on the basis of input from computer models and precision radiation plans, (3) the prescription of drugs is assessed by integrating patient records with decision models especially drug to drug interaction or contraindications, (4) the protocols are successfully applied for the treatment of chronic diseases such as hypertension and diabetes, (5) during intensive care of patients, the fluid balance can be carefully monitored by using computer algorithms which controls the automatic administration of infusion on the basis of fluids given or withdrawn, (6) automatic feedback can be realised for anti-coagulation therapy and for the administration of insulin, (7) infusion algorithms can be better developed if for instance they are based on pharmacokinetic model.

IT-based information services and the support of Medical Informatics have thus become an essential infrastructure required for supporting medical community whether they are practising physicians, teachers or healthcare providers at a medical college hospital or a specialist hospital or an institution. The new electronic technologies have also come to be regarded as a powerful agent for helping the medical specialists for better patient care and their efficient management. The advent of computerised data bases can also help researchers to easily update their knowledge faster with a variety of tools and technologies of information retrieval.

Information high waves, inforoots, cyberspace — all of these terms point to the same feature “Information Revolution” — a result of progress made in telecommunication and computing along with the expansion of mass media. The medical specialists are now beginning to realise the world wide wave (www) and the Internet which is nothing but an informal network of millions of computers around the world. The nature and time skill of future developments in relation to those new technologies and services which relate to equal access by all to medical information and knowledge will be set out. An important consideration has been given to telemedicine service delivery as a part of the range of tele-services which will be offered to all members of medical fraternity. This technology includes facilitating access to all healthcare services for efficiency in diagnosis and treatment, increased provision for healthcare education, particularly Continuing Medical Education. Telemedicine technology, in real terms, is the practice of diagnosis, consultation and treatment between physicians and distant patients through the use of telephone lines, digital communication lines and computers that transmit data for remote television viewing and diagnostic instruments used for medical treatment at a distance.

In other words, telemedicine is the use of advanced telecommunication technology to exchange health information and to provide health services regardless of geographical boundaries. In simpler terms, the FDA (Food and Drug Administration of USA — an authority which regulates the medical field as well) defines telemedicine as “The delivery and provision of health care and consultative services to individual patients and the transmission of information related to care over distances using telecommunication technologies” and this incorporates: (1) Direct clinical, preventive, diagnostic and therapeutic services (2) Consultation and follow up services, (3) Remote monitoring of patients, (4) Rehabilitative services, and (5) Doctors and patients’ education.

Telemedicine is a new terminology where powerful communication system for transmission for medical information in the form of images, patient data record and voice of the specialists over short and long distances are used. The practice of telemedicine was, in fact, discouraged in the past (during the 70s) in view of the high cost of telecommunication, essential equipment (especially the computers), lack of infrastructure standards and specially the cultural acceptance. May be legal hindrances were also factors responsible for the non-utilisation of telemedicine technology. These obstacles, particularly the infrastructure and cost of equipment in recent years (precisely, beginning of the 90s), the spread of communication network and introduction of real time audio-video compression technology have given a new era in telemedicine application in medical practice. Telemedicine has now become one of the merging services in information technology and is a cost-effective medium in clinical practice. In India, Telemedicine can be put to use for utilisation of the vast resources of our medical specialists available in metropolitan and large cities and in some of the institutions of national and international standing.

Our patients can be immensely benefited by the experiences of our medical professionals and also their services can be extended in medical education to the students who are undergoing training in medical colleges and teaching hospitals as undergraduate and postgraduate students. The facilities can further be extended to the para-medical and nursing professionals as well. One of the areas where telemedicine can be profitably used is Continuing Medical Education. Telemedicine has great potential and will certainly have a significant role on the future of medicine than any other modality in the twenty-first century. (1) In the remote areas it can bring high quality medical care where almost none is available at present. (2) It can provide a lifeline to medical expertise and can provide urgently needed health care in primary and community health as well as secondary care hospitals in the country. The technology can universalise and standardise the quality of medical care in the developing countries, especially in India where remote areas are still not easily accessible.

Telemedicine in its true sense is the transmission of medical information in the form of audio, video, text and images of patients from one location to another, using telecommunication channels. The main communication is between two or more clinics, hospitals, institutions and health centres, within a country or outside, for consultation, advice and opinion. Telemedicine also means transfer of expertise from one point to another and it is the fastest means of communication for consultation for improvement and efficiency in diagnosis and treatment. In addition, high quality medical services of specialists and superspecialists can be readily available using telecommunication and computer technology.

The most important aspect of telemedicine is the digital convergence of medical records, charts, X-rays, histopathology slides and medical procedures (including lab. tests) conducted on the patients. This is precisely known as Electronic Patient Record (EPR) in telemedicine practice. Modem computer application and utilisatio of powerful telecommunication systems have created a revolution in that — Telemedicine can be practised as “Real Time” and/or “Store and Forward” multimedia information transfer in patient care, medical education and research.

Real time (synchronous) interactive video conferencing and direct discussion with experts at a distance is becoming a reality. The greatest beneficiary is the community situated at remote areas. We have the means available for electronic transmission of audio, video, text and image data of patients anywhere and at anytime. We can practice telemedicine as “Real Time” (synchronous interactive video-conferencing) and/or “Store and Forward” format based on patient data and record for further consultation, information and advice. Medicine can now extend its reach, regardless of physical distance through real time or near real time two-way transmission of information between places of lesser and/ or greater medical capabilities and expertise. Telemedicine in future, will revolutionise the current clinical medical practice and we can extend instant medical support to a remote or geographically dispersed population in the near future.