Answer Key Ass 1

DEPARTMENT OF INFORMATION TECHNOLOGY
B.TECH - BATCH (2017-2021): III Year/ V SEM
OMD553- TELEHEALTH TECHNOLOGY (R-2017)

ASSESSMENT TEST - I
DATE: TIME: 2 HRS TOTAL MARKS: 60
PART A: (3X2=6 Marks)

1. What are the different types of telemedicine? (C506.1, PO 1,2)
 Live video-conferencing Telemedicine Or Real-time telemedicine
 Store-and-forward or asynchronous Telemedicine
 Remote patient monitoring (RPM)
 Mobile health or mHealth Telemedicine
2. What are the different applications of telemedicine?(C506.1, PO 1,2)

Store-and-forward/asynchronous applications
• Asynchronous telemedicine solutions, commonly referred to as store-and-forward
telemedicine, enable providers to easily store and share patient medical data with other
providers and practices.
Examples of store-and-forward applications:
• Teleradiology solutions that send patient X-rays to another radiologist
• Teledermatology solutions that send patient photos for remote diagnosis
• Telepsychiatry solutions that enable remote behavioral health treatment
Real-time telehealth applications

• Synchronous telemedicine exists as well. It is also known as real-time telehealth and it
facilitates real-time communication between physician and patient. Generally, real-time
telehealth solutions take the form of audio and video communication and replace in-
person visits.
Examples of real-time telemedicine:
• Live video and audio conferencing
• Emergency virtual consultations
• Remote follow-up visits
Remote patient monitoring (RPM), also referred to as telemonitoring, allows providers to track
and monitor their patients with chronic diseases (diabetes, hypertension, etc.). RPM
solutions equip remote caregivers with vital patient data such as blood sugar or blood
pressure levels so that they can review such data in nearly real time and get notified if a
measurement is abnormal. RPM solutions makes it possible for chronically ill, at-risk or
recovery patients to stay at home instead of being confined to a hospital or clinic.
3. Define Telemedicine? Give example. (C506.3, PO 1,2)
 Telemedicine is the remote delivery of healthcare services, such as health
assessments or consultations, over the telecommunications infrastructure. It
allows healthcare providers to evaluate, diagnose and treat patients using common
technology, such as videoconferencing and smartphones, without the need for an
in-person visit.
 These technologies allow communications between patient and medical staff with
both convenience as well as the transmission of medical, imaging and health
informatics data from one site to another.
 It is also used to save lives in critical care and emergency situations.
Examples
1.
PART B: (3X13=39 Marks)

4. Explain the use of POTS & PSTN in the field of telemedicine (C506.2, PO 1,2)
Public Switched Telephone Network System

All of the above systems use digital telecommunications, often ISDN , but with better compression algorithms
it has become possible to transmit video pictures across the public switched telephone network system. Picture
quality is of course limited but connectivity is extremely high, allowing telemedicine to the home .
Irrespective of the type, a videoconferencing system consists of the same basic components:
Codec, which. as we have seen, compresses and decompresses still and video images. The codec also
manipulates the audio information and ensures synchronisation of voice and image. A further task is to control
the interface between the videoconferencing unit and the network and peripherals.
Monitor. to display video images either on a television or monitor according to the NTSC or PAL standards.
Camera: usually an auto-focus, auto-iris, single chip device with remote pan/tilt/zoom to capture information
from any part of the consultation room. The camera can be controlled locally or from the remote site.
Audio system, which needs surprising sophistication to make it an acceptable approximation to normal speech.
The system should provide automatic echo correction and allow full duplex conversation, i.e. the ability to
interrupt and be interrupted. It should also have automatic gain control so that listeners can hear no matter how
close or far a talker is from the microphone.
User interface to make the system easy to operate for all users. A mouse or some other push-button control
may be more acceptable than a keyboard.
The telephone infrastructure at that time could not support the required transmission rates and sales were poor
although the device was a clear 'proof of concept'. AT&T attempted to develop the idea in the late 1960s and
early 1970s, including some telemedicine applications that showed what might be possible if the technology
could be developed further.
The real breakthrough in mass-market terms was made in the early 1990s by Intel with its ProShare personal
videoconferencing product designed to operate over ISDN networks. The market has since expanded to include
PictureTel , VTEL and CLI, all of which offer a range of products and services to suit individual
requirements.
PSTN stands for Public Switched Telephone Network, or the traditional circuit-switched
telephone network. This is the system that has been in general use since the late 1800s.
The phones themselves are known by several names, such as PSTN, landlines, Plain Old
Telephone Service (POTS), or fixed-line telephones.
PSTN phones are widely used and generally still accepted as a standard form of communication.
PSTN Phone Lines Work
Think of a Public Switched Telephone Network (PSTN) as a combination of telephone networks

used worldwide, including telephone lines, fiber optic cables, switching centers, cellular
networks, as well as satellites and cable systems. These help telephones communicate with each
other.
Put simply, when you dial a phone number your call moves through the network to reach its
destination – and two phones get connected. To fully understand how a POTS actually works,
consider what happens when you dial a number from your own phone.
Step #1 – Your telephone set converts sound waves into electrical signals. These signals are then
transmitted to a terminal via a cable.
Step #2 – The terminal collects the electrical signals and transmits these to the central office
(CO).
Step #3 – The central office routes the calls in the form of electrical signals through fiber optic
cable. The fiber optic conduit then carries these signals in the form of light pulses to their final
destination.
Step #4 – Your call is routed to a tandem office (a regional hub responsible for transmitting calls
to distant central offices) or a central office (for local calls).
Step #5 – When your call reaches the right office, the signal is converted back to an electrical
signal and is then routed to a terminal.
Step #6 – The terminal routes the call to the appropriate telephone number. Upon receiving the
call, the telephone set converts the electrical signals back to sound waves.
This may sound complicated, but the thing to remember is that it takes a few seconds for your
call to reach its destination. This process is facilitated by using fiber optic cables and a global
network of switching centers.
PSTN – Understanding The Art of Switching
Now, let’s have a look at each of the four types of switching which take place at different levels.
1. The Local Exchange
A local exchange – which may consist of one or more exchanges – hooks up subscribers to a
PSTN line. Also known as a central office or a switching exchange, a telephone exchange may
have as many as 10,000 lines. All telephones are connected to the local exchange in a specific
area. Interestingly, if you were to dial the number of your supplier located in the building next to
yours, the call won’t leave your local exchange and will be routed to the supplier as soon as it
reaches the exchange.
The exchange then identifies the number dialed so it can route the call towards the correct end
destination. This process works as follows:
The first three digits of a phone number represent the exchange (the local switch), while the last
four digits identify the individual subscriber within that exchange.
This means that when you dial a number and it reaches your local exchange, your call is
immediately linked to the subscriber without the need for any further routing.
2. The Tandem Office
Also known as a junction network, a tandem office serves a large geographical area comprising
several local exchanges while managing switches between local exchanges.
Let’s say you dialed the number of a client who lives in the same city but in another suburb. In
this case your call will be routed to a tandem office from your local exchange, and the tandem
office will route the signal on to the local exchange near your client’s location.
3. The Toll Office
This is where any national long-distance switching takes place.
A toll office is connected to all the tandem offices. For instance, if you have an office in another
city you’ll find that, whenever you dial that branch’s number, your call will be switched through
a toll office.
4. The International Gateway
International gateways manage international call switching, routing domestic calls to the
appropriate countries.
Plain Old Telephone Service

 POTS is an acronym for plain old telephone service, which refers to the standard low
speed, analog telephone service that is still used by most homes and many businesses.
 The term is sometimes used to distinguish that service from the newer
telecommunications services which are digital and have much larger bandwidths. These
include ADSL (asymmetric digital subscriber line), ISDN (integrated services digital
network) and FDDI (fiber distributed data interface).
 POTS is basically an analog voice transmission phone system implemented over copper
twisted pair wires. It is the phone line technology most of us grew up with at home and is
exactly what you think it is: copper wires dangling overhead, carrying your voice from
one place to another.
 POTS networks were created to facilitate voice communication over copper cables that
traversed countries and continents, and it has been the standard voice-grade telephone
system used by residences and businesses across the world since the 1880’s. But the
POTS most of us are familiar with is an upgrade over the rudimentary phone system
invented by Alexander Graham Bell.
 The newer services provide some part of their channels for POTS while using most of
their bandwidth for digital data transmission. The newer services also make possible
added features such as call waiting or call forwarding.
 POTS utilizes the lowest 4kHz of bandwidth on twisted pair wiring (i.e., conventional
low-speed copper wiring). Any service sharing a line with POTS (e.g., DSL) must either
use frequencies above POTS or convert POTS to digital signals and interleave them with
other data signals.

 POTS, is a term which describes the voice-grade telephone service that remains the basic
form of residential and small business service connection to the telephone network in
most parts of the world. The system was originally known as the Post Office Telephone
Service or Post Office Telephone System. Today the term Plain Old Telephone Service is
used, after the services were removed from the control of national post offices.
 The pair of wires from the central switch office to a subscriber’s home was called the
subscriber loop. It was typically powered by 40V(DC) and backed up by a large bank of
batteries in the central office, resulting in continuation of service during most commercial
power outages.
 This 64Kbps service is a bi-directional, or full duplex, voice path with limited frequency
range of 300 to 3400 Hz: in other words, a signal to carry the sound of the human voice
both ways at once. Today, it is also used for internet access via a dial modem, DSL, fax,
credit card terminals, etc.
 Users accessing the Internet with the same twisted pair copper wiring as is used by their
telephone are using a POTS connection. The TCP/IP (transmission control
protocol/Internet protocol) digital data from their computer or LAN (local area network)
is converted to analog format using a modem prior to transmission over the POTS.
The POTS setup has remained virtually the same for decades. There have been many upgrades to
usher components of the POTS telephone system into the digital era, but the copper wire
connection has weathered the storm.
As far as the mechanics of a POTS lines go, this phone service works by establishing a dedicated
circuit between Point A and Point B for the duration of a transmission.
Circuit Switching
Back in the old days, circuit switching was the reason you needed an operator’s assistance when
making calls.
In those days, operators would sit by one giant wooden switchboard, plugging copper wires into
a common patch panel. In the case of connections that required two exchanges, two operators
would go about simultaneously plugging the caller’s and receiver’s wires into the same inter-
exchange wire.
This wire was known as a “trunk”.
Long distance calls were unbearably costly because calling long distance was akin to renting the
use of a very long piece of copper wire each time you wanted to make a call.
Transistors
The transistor heralded the electronic exchange era, which slowly paved the way for the digital
network. Current phone lines have been upgraded to carry digital signals in the form of
“packets.” Packet-based technology does not dominate the transmission channel by demanding a
continuously open and dedicated circuit, unlike its analog counterpart. Rather, it uses the
underlying network to transmit voice (and data) messages independently through the switches. A
copper line is a bi-directional 64Kbps service capable of carrying human voice both ways at the
same time
Modems
This is a device that was designed to exploit the digital nature of the public switched telephone
network without overhauling your entire phone system. This should come as good news for
small business owners who are not planning to upgrade their analog communications systems
any time soon, especially considering the wealth of options available on the market.
5. Discuss about the Global and Indian scenarios in the field of telemedicine (C506.1, PO
1,2)
Indian Scenario
Initiatives
In a developing country such as India, there is huge inequality in health-care distribution.
Although nearly 75% of Indians live in rural villages, more than 75% of Indian doctors are based
in cities. Most of the 620 million rural Indians lack access to basic healthcare facilities and the
Indian government spends just 0.9% of the country's annual gross domestic product on health,
and little of this spending reaches remote rural areas. The poor infrastructure of rural health-
centers makes it impossible to retain doctors in villages, who feel that they become
professionally isolated and outdated if stationed in remote areas.
In addition, poor Indian villagers spend most of their out-of-pocket health- expenses on travel to
the specialty hospitals in the city and for staying in the city along with their escorts. A recent
study conducted by the Indian Institute of Public Opinion found that 89% of rural Indian patients
have to travel about 8 km to access basic medical treatment, and the rest have to travel even
farther. Telemedicine may turn out to be the cheapest, as well as the fastest, way to bridge the
rural–urban health divide. Taking into account India's huge strides in the field of information and
communication technology, telemedicine could help to bring specialized healthcare to the
remotest corners of the country.
The efficacy of telemedicine has already been shown through the network established by the
Indian Space Research Organization (ISRO), which has connected 22 super specialty hospitals
with 78 rural and remote hospitals across the country, through its geo-stationary satellites. This
network has enabled thousands of patients in remote places, such as Jammu and Kashmir,
Andaman and Nicobar Islands, the Lakshadweep Islands, and tribal areas of the central and
northeastern regions of India, to gain access to consultations with experts in super-specialty
medical institutions.
ISRO has also provided connectivity for mobile telemedicine units in villages, particularly in the
areas of community health and ophthalmology. Other then that, both public and private entities
are aggressively pursuing the use of telemedicine to hasten diagnostics and treatment of a variety
of diseases in India.
 Private hospitals such as Apollo Hospital Group.

 Escorts Heart Institute and Fortis Healthcare.
 The Apollo Hospital Group has networked dozens of remote rural hospitals providing
digital connections to one of its main facilities in. In one example, Apollo has set up a 50-
bed telemedicine center in Aragnoda, a small village in the Andhra Pradesh section of
south India. The facility is equipped with CT-scans, X-ray and ECG equipment as well as
an integrated laboratory and is linked to Apollo's specialized hospitals with connectivity
is conducted through the use of ISDN lines and VSAT. The Indian government has also
made important commitments to telemedicine by reducing import tariffs on infrastructure
equipment
 Department of Information Technology (DIT)
 Indian Space Research Organization
 NEC Telemedicine program for North-Eastern states
 Asia Heart Foundation
 Stategovernments
Hindrances to Telemedicine
 Financial unavailability: There have been several isolated initiatives from various
organizations and hospitals for the implementation of e-medicine projects in India; but
the technology and communication costs, being too high, make it financially unfeasible
 Lack of basic amenities: In India, nearly 40% of the population lives below the poverty
level. Basic amenities like transportation, electricity, telecommunication, safe drinking-
water, primary health-services, etc., are missing. Any technological advancement can’t
change a bit when a person “has nothing” to change.
 Literacy rate and diversity in languages: Only 65.38 % of India’s population is literate,
with only 2% well-versed in English. So the rest of the people are facing a problem in
adopting telemedicine. Also, the presence of a large number of regional languages makes
the applicability of a single software difficult for the entire country.
Advantages of Telemedicine in India

 Doctors licensed to practice all over India
 Maximum utilization of limited resources
 Saves travel, time and money
 Make geographical history
 Motivation for computer literacy among doctors
 Useful in designing credits for re-certification of doctors
A time is approaching when telemedicine/e-health initially shall be visibly
practiced in the majority of Indian hospitals, as a separate department, before eventually fusing
into the respective medical specialties.
Global scenario
Telemedicine can also be concisely referred to as “the use of information and telecommunication
technologies (ICT) in medicine” . Telemedicine is just not only for remote monitoring or
diagnosing a patient (comparative performance of seven long-running telemedicine networks
delivering humanitarian services .It also includes e-learning techniques (to remotely deliver
education both to health care workers and to patients), and teleconsultation (aka telecounseling
or expert second opinion) services. This latter refers to any consultation between doctors or
between doctors and patients on a network or video link (e.g., Facetime, intranet, Internet,
Skype, etc.), as opposed to the “in person” counseling where no ICT is needed to manage the
interaction between the patient and the physician(s).
In developed countries several programs have been deployed, and they have been promptly
reported for 10–15 years , where the program has been mainly used for remote education (76%
of the considered cases), without neglecting other goals such as wound cases (55%), and
psychiatry cases (54%), and store-and-forward ECG (ElectroCardioGraphy) recordings.
To provide the reader with an economic evaluation of the effort, the telemedicine market in
Europe increased from an amount of €4.7 billion in 2007 to the amount of €11.2 billion in 2012 –
the European Commission (EU) estimates . Additional world-wide estimations assert that the
global telehome and telemedicine market reached an amount of US$ 13.8 billion 2012, US$ 16.3
billion 2013, US$ 19.2 billion 2014, and this market is expected to grow up to US$ 35.1 billion
in 2018, US$ 43.4 billion in 2019, with a compound annual growth (CAGR) of 17.7%. Some
more estimations evaluate that the European telemedicine market grew from US$ 3.1 billion in
2010 to US$ 4.8 billion in 2011, and will almost triple to US$ 12.6 billion in 2019 at a CAGR of
12.82%; at the worldwide level, the market of telemedicine reached an amount of US$ 14.4
billion in 2015, and is expected to grow up to US$ 34.0 billion in 2020, with CAGR of 18.6%.
Much less effort has been spent for similar initiatives in developing countries. Probably, this is
due both to the much smaller return of investment (ROI), to a limited budget available, and to the
greater difficulties expected or encountered also due to the lack of technological infrastructures.
Moreover, while telemedicine programs in developed countries in most cases may easily deploy
an emergency strategy, such as sending out an helicopter to rescue the patient and to transfer
him/her to the nearest hospital in a very short time, similar situations in developing countries are
generally more expensive and much harder to be deployed. Finally, in developed countries,
telemedicine is side-by-side to more conventional health care, completing it, while in developing
countries telemedicine in most cases is an alternative, or even the only alternative, to
conventional health care. Nevertheless, telemedicine applications in developing countries could
be a leverage to provide wide populations with basic health care services and to close the
distance between rural areas and specialized hospitals usually located in big cities.
Efficacy and the cost-effectiveness of telemedicine compared with conventional health care still
are to be properly evaluated in fact, major aspects to be considered include the amount of saved
lives (e.g., some people would have died without the aid of a telemedicine system), and the
quality of life of saved people (e.g., some people would have been completely restored if the
telemedicine system could suggest them a first-aid assistance). As for the cost-effectiveness, to
the best of our knowledge, are the only ones to measure the economic benefits achieved by a
telemedicine program: they just sum up the travel costs to move a specialist physician from a
main hospital to the remote hospital, or to move the patients from the remote hospitals to the
main hospital.
According to the previous considerations, telemedicine applications in developing countries need

to be studied, designed, and evaluated according to specific criteria, which have to take into
account cultural, environmental, organizational, and economic peculiarities of the considered
countries and populations.
6. Describe in detail about the role of Telecommunication in the field of telehealth (C506.2,
PO 1,2)
Data Communication Circuits

The underlying purpose of a digital communications circuit is to provide a transmission path
between locations and to transfer digital information from one station (node, where
computers or other digital equipment are located) to another using electronic circuits. Data
communications circuits utilize electronic communications equipment and facilities to
interconnect digital computer equipment. Communication facilities are physical means of
interconnecting stations and are provided to data communications users through public
telephone networks (PTN), public data networks (PDN), and a multitude of private data
communications systems.
The following figure shows a simple two-station data communications circuit. The
main components are:
Source: - This device generates the data to be transmitted; examples are mainframe
computer, personal computer, workstation etc. The source equipment provides a means for
humans to enter data into system.
Transmitter: - A transmitter transforms and encodes the information in such a way as to
produce electromagnetic signals that can be transmitted across some sort of transmission
system. For example, a modem takes a digital bit stream from an attached device such as a
personal computer and transforms that bit stream into an analog signal that can be handled
by t he telephone network.
Transmission medium: - The transmission medium carries the encoded signals from the
transmitter to the receiver. Different types of transmission media include free-space radio
transmission (i.e. all forms of wireless transmission) and physical facilities such as metallic
and optical fiber cables.
Receiver: - The receiver accepts the signal from the transmission medium and converts it
into a form that can be handled by the destination device.
Destination: - Takes the incoming data from the receiver and can be any kind of digital
equipment like the source.
Network Classifications
One way to categorize the different types of computer netw ork designs is by their scope or
scale. Common examples of area network types are:
LAN - Local Area Network

WLAN - Wireless Local Area Network

WAN - Wide Area Network

MAN - Metropolitan Area Network

SAN - Storage Area Network, System Area Network, Server Area Network, or sometimes Small Area
Network
CAN - Campus Area Network, Controller Area Network, or sometimes Cluster Area Network
PAN - Personal Area Network


DAN - Desk Area Network
requirements.

Wireless Communication Infrastructure-Telehealth

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Mobile Telemedicine Unit
The telecommunication equipment for MTU allows transmitting results of medical examinations to
hospitals and receives corresponding conclusions, recommendations and instructions, plus providing
national medical centers and MTU with videoconference services. The telecommunication equipment
for MTU can be used for training purposes to teach local population about healthy life style, methods of
caring for sick persons, various social and other issues.
The MTU is equipped with a fast deploying ground satellite station (GSS) intended for transfer and
receipt of digital information through the allocated communication networks using channels of the
geostationary satellite. The station provides for delivery of information from any location within the area
serviced by the satellite, to central or intermediary stations-nodes of the communication network.
PART C: (1X15 = 15 Marks)
7. Write about the application of LAN & WAN technology in the field of telehealth
(C506.4, PO 1,2,3,4)


ASSESSMENT TEST - I

2. 1. What is ANT?(C506.2 PO.1,2)
2. What are the different organs of telemedicine? (C506.1, PO 1,2)
Types of Telemedicine
Telemedicine is the use of medical information shared from one site to another using electronic
communications to improve patient’s clinical health status.
3.
1. Live video-conferencing Telemedicine Or Real-time telemedicine
Also known as synchronous video, live video-conferencing is a live, two-way interaction
between a person and a healthcare provider using audiovisual telecommunications technology.
2. Store-and-forward or asynchronous Telemedicine

Store-and-forward is involves acquiring medical data (like medical images, biosignals etc.) and
then transmitting this data to a doctor or medical specialist at a convenient time for assessment
offline. It does not require the presence of both parties at the same time.
3. Remote patient monitoring (RPM)

RPM is the collection of personal health and medical data from a patient or resident in one
location that is then transferred electronically to a nurse, caregiver, or physician in a different
location for monitoring purposes.
3. What are the different applications of telemedicine?.(C506.1 PO.1,2)

 Teleradiology – use of ICT to transmit digital radiological images (e.g. X-ray images)
from one location to another for the purpose of interpretation and/or consultation.
 Telepathology – use of ICT to transmit digitized pathological results (e.g. microscopic
images of cells) for the purpose of interpretation and/or consultation.
 Teledermatology – use of ICT to transmit medical information concerning skin
conditions (e.g. tumours of the skin) for the purpose of interpretation and/or consultation.
 Telepsychiatry – use of ICT for psychiatric evaluations and/or consultation via video
And telephony.
(C506.2, PO 1,2,3,4)
Local area network: A local area network (LAN) is a network that connects computers
and devices in a limited geographical area such as home, school, computer laboratory,
office
building, or closely positioned group of buildings. LANs use a network operating system to
provide two-way communications at bit rates in the range of 10 Mbps to 100 Mbps. In
addition to operating in a limited space, LANs are also typically owned, controlled, and
managed by a single person or organization. They also tend to use certain connectivity
technologies, primarily Ethernet and Token Ring.
MERITS
• Cost reductions through sharing of information and databases, resources and network
services.
• Increased information exchange between different departments in an organization, or

between individuals.
• The trend to automate communication and manufacturing process.
DEMERITS
Special security measures are needed to stop users from using programs and data that they
should not have access to;
• Networks are difficult to set up and need to be maintained by skilled technicians.
• If the file server develops a serious fault, all the users are affected, rather than just one user
in the case of a stand-alone machine.
 There are three topologies of LAN Network

.
Wide Area Network (WAN).
A wide area network, or WAN, spans a large geographical area, often a country or continent. It
contains a collection of machines intended for running user (i.e., application) programs. These
machines are called as hosts. The hosts are connected by a communication subnet, or just subnet
for short. The hosts are owned by the customers (e.g., people's personal computers), whereas the
communication subnet is typically owned and operated by a telephone company or Internet
service provider. The job of the subnet is to carry messages from host to host, just as the
telephone system carries words from speaker to listener.
ADVANTAGES OF WAN
• Covers a large geographical area so long distance businesses can connect on the one network.
• Shares software and resources with connecting workstations.
• Messages can be sent very quickly to anyone else on the network. These messages can have
pictures, sounds, or data included with them.
• Expensive things can be shared by all the computers on the network without having to buy a
different peripheral for each computer.
• Everyone on the network can use the same data.
DISADVANTAGES OF WAN
• Need a good firewall to restrict outsiders from entering and disrupting the network
• Setting up a network can be an expensive, slow and complicated.
• Once set up, maintaining a network is a full-time job which requires network supervisors and
technicians to be employed.
• Security is a real issue when many different people have the ability to use information from
other computers. Protection against hackers and viruses adds more complexity and expense.
Technologies Involved
• Medical Instrumentation
Sensing Bio-medical Signals,
Medical Imaging, Measurement of Physical Parameters e.g. Body Temperature, Pressure etc.
• Telecommunication Technology
Trans-receiver on different communication channels and network such as, on wired network,
wireless medium etc.
• Information Technology
Information representation, storage, retrieval, processing, and presentation.
5. What are the different multimedia data in the field of telehealth? (C506.2, PO 1,2)
MULTIMEDIA- TEXT, AUDIO, VIDEO, DATA

 Multimedia involves multiple modalities of text, audio, images, drawings, animation, and video.
 Examples of how these modalities are put to use:
1. Tele-medicine
2. Video teleconferencing.
3. Distributed lectures for higher education.
4. Co-operative work environments.
Multimedia Telemedcine System(MTS)

 A multimedia telemedicine system (MTS) using Transfer Control Protocol and Internet Protocol
(TCP/IP) over the Internet is developed
 Real-time data, including audio, video and instant message (IM), and non-real-time data, including
vital sign signals, radiological images with DICOM 3.0, file, bio-signal, bio-data can be exchanged
on the system.
 Discrete (or Time independent) Media:

 E.g., Text, graphics and images, have no real-time demands.
 Termed discrete media.
 Continuous (or Time dependent) media:
 Information becomes available at different time intervals.
 Time intervals can be periodic or a periodic depending on the nature of the media.
 Audio and video are examples of periodic, continuous media.
 Orchestrated Multimedia:
 Capture and/or generation of information done by retrieving stored objects.
 Stored multimedia lecture presentations, on-demand servers, and other multimedia database
applications fall under this category.
 Live Multimedia:
 Information generated from devices such as video camera, microphone or keyboard.
 Multimedia teleconferencing and panel discussion applications fall under this category.
 Participants communicate among themselves by exchanging multimedia information
generated from video camera or microphone.
Multimedia Telemedicine System – Network Architecture

Discrete Media – Size per Page
Media Size
Text 9.4KB
Graphics 2.8KB
Bitmap Picture 300-900KB
A4 15-247MB
Continuous Media – Bandwidth
Media Bandwidth
Audio digital telephony 64Kb/s

Audio stereo CD quality 1.34Mb/s
Video PAL 176Mb/s
Video HDTV 936Mb/s
Types of Telemedicine Information

 Text and Data
 Audio
 Video
 Frame Rate and Bandwidth
In a face-to-face consultation, a physician might use some combination of all five senses-sight, sound, touch,
smell and taste-to assess a patient’s condition.
The first three methods are by far the most common and the sensory data are transmitted directly from the
patient to the observer. In telemedicine, however, the sensory data are first converted into electrical impulses
for transmission to the remote physician. Methods to convert smell and taste stimuli into electrical signals are
still in the experimental stage and. while the sense of touch can be translated successfully into an electrical
equivalent, the reverse process is more difficult and not well understood. Hence. A teleconsultation relies
primarily on the two senses of sight and sound. The information (useful data) derived from these senses can be
divided into four types:
 text and data;
 audio;
 still (single) images;
 video (sequential images).
Table 3 gives telemedicine examples of these types along with their typical file size in kilo- or megabytes
following digitisation. The wide range of electronic files sizes from these sources suggests the need to match
the choice and performance characteristics of the telemedicine equipment to the clinical need. Under- and
over-specification of systems can otherwise lead to disappointment and premature abandonment of a promising
project.
Table 3. Typical examples of telemedicine information
Source Type Typical file size

Patient notes Text < 10KB
Electronic stethoscope Audio 100 KB
Chest X-ray Still image 1 MB
Foetal ultrasound (30 s) Video 10 MB
Text and Data

Electronic documents such as reports, correspondence or medical records containing ASCII or Unicode text
and numerical information can be transmitted directly in digital format. The digitized file can be edited with a
word processor, database or spreadsheet program but this is seldom necessary, or even desirable, since the
transmitted information is invariably ‘read-only’.
If a document is only available in paper format then it can be digitized for transmission with either a scanner
(e.g. fax) or a document camera. Unless the text is subjected to optical character recognition it will be in
bitmapped format and cannot be edited. Frequently, textual information is needed before the teleconsultation
takes place or later, as a consequence of the process. In these cases it is more efficient to send the documents
by post or, better still, as attachments to emails .
Audio
The public switched telephone network (PSTN but sometimes known as the plain old telephone system, POTS)
can be used to transmit sound (e.g. speech) and establish a remote diagnosis. However, the quality (ease of
understanding) and bandwidth (capacity to carry information) of analogue telephony are seldom adequate for
medical applications. In contrast, digital signals can be transmitted over networks for large distances without
degradation. Digital signals can also be manipulated to improve system performance.
An analogue sound is digitised by sampling its amplitude at discrete time intervals to recreate the waveform.
The discrete nature of the digitization process introduces quantisation or amplitude round-off errors as the
digital sample value approximates the analogue signal at a given instant. The human ear detects this error as a
hissing noise and to reduce the effect the sample value should have a resolution of at least 1 in 65 536 (216),
giving a 16-bit quantisation error.
3.2.5 Video
Our perception of video is conditioned by television to the extent that a videoconference between patient or
carer and consultant is regarded as the normal practice of telemedicine. Where video is needed, for example. to
demonstrate a patient’s mobility after a hip replacement, it is usually sufficient to use a commercial
videoconferencing unit (Section 3.3.2) rather than the much more expensive broadcast television. The output
from such units approaches broadcast quality.
An important consideration for international teleconsultations is the compatibility of the analogue video
signals, and therefore the video equipment, in different countries. There are two widely used formats for
analogue video:
The National Television Standard Committee (NTSC) system adopted in North America and Japan, having
525 lines per picture and a frame rate of 30 pictures per second;
The Phase Alternating Line (PAL) system used throughout Western Europe and Australasia, having 625
lines per picture and a frame rate of 25 pictures per second.
Most modern television receivers and video recorders are able to convert signals from one standard to another.
The Common intermediate Format (CIF) is a format introduced to provide compatibility between NTSC and
PAL and offers a lower resolution of 288 lines per picture at 30 pictures per second.
Frame Rate and Bandwidth

Video frame rates of 25 discrete pictures per second and above fool the human brain into perceiving
continuous and smooth motion. However, when video compression takes place, the display frame rate may fall
due to the time needed to decompress the images. The effective frame rate may drop to 7.5. 10 or 15 frames
per second.
The ultimate solution to this problem is of course to increase the bandwidth at a cost. A no-cost, sometimes
acceptable compromise is to reduce the size of
the display window and hence the number of pixels needed to output a frame.
Naturally, the window size must be large enough to allow a valid teleconsultation to take place.
6. Write about the history and evolution of telemedicine(C506.1, PO 1,2)

History of Telemedicine
Various forms of telecommunication and information technologies have evolved with time. On
these bases, we can identify four phases of the development of tele-health corresponding to the
use of these technologies (Table-1).
Table – 1: Phases of Tele-health Development

Development phase Approximate time frame
Telegraphy and telephony 1840s-1920s
Radio 1920 onwards till 1950s
Television/space technologies 1950s onwards till 1980s
Digital technologies 1990s onwards
 Clinical or healthcare information over telephone, or broadcasting it over radio stations..
 Marconi’s invention of the radio-telegraph in 1897, which was used during the American
CivilWar to send casualty lists and order supplies.
 1906:ECGTransmission
Einthoven, the father of electrocardiography, first investigated on ECG transmission over
telephone lines in 1906.
 1920s: Help for ships

Telemedicine dates back to the 1920s. During this time, radios were used to link
physicians standing watch at shore stations to assist ships at sea that had medical
emergencies.
 1924: The first exposition of Telecare --- TELEDACTYL

Perhaps it was the cover showed below of "Radio News" magazine from April 1924. The
article even includes a spoof electronic circuit diagram which combined all the gadgets of
the day into this latest marvel! . Hugo Gernsback, predicted that physicians would use not
the telephone, but radio and TV to communicate with patients.
 1955 Telepsychiatry : Closed-circuit television service begun in 1955; used in hospitals
The Nebraska Psychiatric Institute developed a two-way link with Norfolk State Hospital,
112 miles away, in 1964 with further extensions in 1971. This project is one of the first of
many examples of tele-psychiatry.
 1967: Massachusetts General Hospital

This station was established in 1967 to provide occupational health services to airport
employees and to deliver emergency care and medical attention to travelers.
 The National Aeronautics and Space Administration’s (NASA) efforts in tele-health
began in the early 1960s when humans began flying in space. Physiological parameters
were telemetered from both the spacecraft and the space suits during missions.
 1970s: Satellite telemedicine

Via ATS-6 satellites. In these projects, paramedics in remote Alaskan and Canadian
villages were linked with hospitals in distant towns or cities.
 Project STARPAHC - Space Technology Applied to Rural Papago Advanced Health-

Care. STARPAHC aimed at providing medical care to astronauts in space and to the
Papago Indian Reservation in Arizona. This service was carried out through a van that
was equipped with a variety of medical instruments, including electrocardiograph and x-
ray. The van was linked to the Public Health Service hospital and another hospital with
specialists, by a two-way microwave tele-health and audio transmission.
 In the later parts of 1970s, Alaska Satellite Biomedical Demonstration Program and
various other Canadian projects were begun, to serve far-flung areas.
 The first truly international tele-health program, known as Space Bridge, was
implemented by NASA. It was done to provide relief to people after a terrible earthquake
jolted Armenia in 1988 and cased severe devastation.
 The North-West Tele-health Project set up in Queensland, Australia, was the only major
tele-health project outside North America until 1990. This project was designed to serve
rural communities. The project-goals were to provide healthcare to people in five remote
towns, south of the Gulf of Carpentaria.
 This development was followed by Meaningful Use regulation and the Affordable Care
Act in 2010 where Accountable Care Organizations (ACOs) were created to push for the
maturation of telehealth capabilities.
 It’s a fairly obvious statement to say that 2016 was the year of telehealth. Even though
the push for its inception started in late 2014 and showed signs of becoming a real
movement in 2015.
 In 2016, $16 million was given by the federal government to improve access to
healthcare in rural areas. Some of the money was designated for the use of the technology
for veterans and others. While we’re not where many thought we might be, especially
more than 120 years ago, most physicians think the effort is a top priority and will lead to
improved patient outcomes and access to care.
 In 2017, the concept will be unrestricted, paid for and covered, and continue expanding to
a wider audience. For the arguments of telehealth being used to serve the disenfranchised
and the rural poor, telemedicine is set for widespread use.
 There is an expansion of the technology through the use of internet-connected everything

devices and as virtual medical facilities take shape, but there’s been excitement about the
concept before now. Telehealth is likely a real concept now, but even with new
developments, that doesn’t mean all of this can’t be derailed.
The Evolution of Telehealth

One of the landmark publications of the past couple of decades, Crossing the Quality Chasm,
stated, “information technology must play a central role in the redesign of the health care system
if a substantial improvement in quality is to be achieved”. Nowhere is this more true than in rural
communities. New knowledge and new science are being developed all the time. When some
people have access to that new knowledge and expertise and other people do not, disparities
grow. Advances in telecommunication and information technology can help overcome some of
these disparities by redistributing that knowledge and expertise to when and where it is needed.
HOME- AND COMMUNITY-BASED CARE
Health care in the home-based setting has a long history. For example, an 1879 article in the
Lancet talked about using the telephone to reduce unnecessary office visits. In 1925, a cover of
Science and Invention magazine showed a doctor diagnosing a patient by radio, and within
envisioned a device that would allow for the video examination of a patient over distance. Home
monitoring developed more fully in the Mercury space program when the National Aeronautics
and Space Administration (NASA) began performing physiologic monitoring over a distance.
NASA further developed this technology with a pilot with the Papago Indians, the Space
Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project.
The biggest need in home- and community-based care relates to chronic disease. The 100 million
Americans with chronic disease account for about 75 percent of health care expenditures.
Traditionally, chronic disease has been managed through an episodic office-based model rather
than a care management model, which uses frequent patient contact and regular physiologic
measurement. Use of technologies for chronic disease care management has been associated with
reductions in hospitalizations, readmissions, lengths of stay, and costs; improvement in some
physiologic measures; high rates of satisfaction; and better adherence to medication. Studies of
home monitoring programs have shown specific improvements in the management of
hypertension, congestive heart failure, and diabetes.
OFFICE-BASED TELEMEDICINE
Telemedicine has also been used for decades in clinical settings. In 1906, the inventor of the
electrocardiogram published a paper on the telecardiogram. Since the 1920s, the radio has been
used to give medical advice to clinics on ships. Alaska has been a model for the development and
use of telemedicine for decades. For example, community health aides in small villages can
perform otoscopy and audiometry, and the information can be sent to specialists in Anchorage or
Fairbanks to make the determination of whether a patient needs to travel to the specialist for
more definitive treatment. Today, we think of office-based telemedicine as flat-screen, high-
definition units with peripheral devices that can aid in physical examination of the patient. There
are a lot of these units out there, all of which do not talk to each other, and some of which use
proprietary communications methods. If telemedicine is to become as ubiquitous as the
telephone, communications standards will be needed.
Store and forward (S&F), or asynchronous, technologies have been a great advance. For
example, in ophthalmology and optometry, non-mydriatic cameras can be used to perform retinal
screenings in diabetics without needing to dilate the eyes; this has increased screening rates.
Teledentistry has been used to by dental hygienists and dentists to improve access to oral health
care. Dermatology and psychology are two of the biggest areas for telemedicine. Since the
1990s, studies have shown high rates of agreement between diagnoses made in person and
diagnoses made via teledermatology.
ANCILLARY TELEMEDICINE SERVICES

Teleradiology
Teleradiology has been used for at least 60 years. In the past, film was passed through a digitizer;
now most systems use direct digital capture, which allows images to be read overnight in other
countries. Radiologists have promoted the Digital Imaging and Communications in Medicine
(DICOM) standard for transmitting and storing data. By the late 1990s, studies showed that
teleradiology reduced transports for head injuries out of rural areas and that the availability of
teleconsultation with a radiologist significantly affected diagnosis and treatment plans.
Telepathology
Telepathology is less common than teleradiology, but digitization of pathology slides is
becoming much more common. These are very large files, which require the ability to view color
images under different magnifications. A lot of people were concerned about moving these large
files across firewalls, but now a number of models being developed have the image sitting on a
server and the image can be viewed over distance without needing to be moved. Studies have
shown the value of telepathology.
Telepharmacology
Pharmacy has been practiced over distance for a long time. Telepharmacy is facilitated by
computerized physician order entry, remote review, and even remote dispensing. Combining that
with video, being able to review medications, and conducting a video consultation with a patient
allows the whole pharmacy visit to occur over distance. In one recent study on 47 cancer
patients, 27,000 miles of travel were saved because of telepharmacy.
HOSPITAL-BASED TELEMEDICINE
Probably one of the earliest and most famous uses of hospital-based telemedicine was in the late
1950s and early 1960s when a closed-circuit television link was established between the
Nebraska Psychiatric Institute and Norfolk State Hospital for psychiatric consultations. Hospital-
based telemedicine is growing quickly in two areas: stroke care and care in the intensive care
unit (ICU). Evidence shows that with good imaging, high-quality stroke exams can be done over
distance. Although the literature on tele-ICU has been mixed, recent studies indicate associated
reductions in length of stay, mortality, and costs.
A number of devices are being used in inpatient setting as well as in skilled nursing facilities.
Telemedicine reduces avoidable visits to emergency departments for skilled nursing patients.
Some rural skilled nursing facilities exist in communities that do not have physicians, and getting
physicians there urgently can be a challenge.
7. Explain the use of POTS & PSTN in the field of telemedicine (C506.2, PO 1,2)

requirements.
PSTN Phone Lines Work
Think of a Public Switched Telephone Network (PSTN) as a combination of telephone networks

used worldwide, including telephone lines, fiber optic cables, switching centers, cellular
networks, as well as satellites and cable systems. These help telephones communicate with each
other.
Put simply, when you dial a phone number your call moves through the network to reach its
destination – and two phones get connected. To fully understand how a POTS actually works,
consider what happens when you dial a number from your own phone.
Step #1 – Your telephone set converts sound waves into electrical signals. These signals are then
transmitted to a terminal via a cable.
Step #2 – The terminal collects the electrical signals and transmits these to the central office
(CO).
Step #3 – The central office routes the calls in the form of electrical signals through fiber optic
cable. The fiber optic conduit then carries these signals in the form of light pulses to their final
destination.
Step #4 – Your call is routed to a tandem office (a regional hub responsible for transmitting calls
to distant central offices) or a central office (for local calls).
Step #5 – When your call reaches the right office, the signal is converted back to an electrical
signal and is then routed to a terminal.
Step #6 – The terminal routes the call to the appropriate telephone number. Upon receiving the
call, the telephone set converts the electrical signals back to sound waves.
This may sound complicated, but the thing to remember is that it takes a few seconds for your
call to reach its destination. This process is facilitated by using fiber optic cables and a global
network of switching centers.
PSTN – Understanding The Art of Switching
Now, let’s have a look at each of the four types of switching which take place at different levels.
1. The Local Exchange
A local exchange – which may consist of one or more exchanges – hooks up subscribers to a
PSTN line. Also known as a central office or a switching exchange, a telephone exchange may
have as many as 10,000 lines. All telephones are connected to the local exchange in a specific
area. Interestingly, if you were to dial the number of your supplier located in the building next to
yours, the call won’t leave your local exchange and will be routed to the supplier as soon as it
reaches the exchange.
The exchange then identifies the number dialed so it can route the call towards the correct end
destination. This process works as follows:
The first three digits of a phone number represent the exchange (the local switch), while the last
four digits identify the individual subscriber within that exchange.
This means that when you dial a number and it reaches your local exchange, your call is
immediately linked to the subscriber without the need for any further routing.
2. The Tandem Office

Also known as a junction network, a tandem office serves a large geographical area comprising
several local exchanges while managing switches between local exchanges.
Let’s say you dialed the number of a client who lives in the same city but in another suburb. In
this case your call will be routed to a tandem office from your local exchange, and the tandem
office will route the signal on to the local exchange near your client’s location.
3. The Toll Office
This is where any national long-distance switching takes place.
A toll office is connected to all the tandem offices. For instance, if you have an office in another
city you’ll find that, whenever you dial that branch’s number, your call will be switched through
a toll office.
4. The International Gateway
International gateways manage international call switching, routing domestic calls to the
appropriate countries.
 The newer services provide some part of their channels for POTS while using most of
their bandwidth for digital data transmission. The newer services also make possible
added features such as call waiting or call forwarding.
 POTS utilizes the lowest 4kHz of bandwidth on twisted pair wiring (i.e., conventional
low-speed copper wiring). Any service sharing a line with POTS (e.g., DSL) must either
use frequencies above POTS or convert POTS to digital signals and interleave them with
other data signals.

 POTS, is a term which describes the voice-grade telephone service that remains the basic
form of residential and small business service connection to the telephone network in
most parts of the world. The system was originally known as the Post Office Telephone
Service or Post Office Telephone System. Today the term Plain Old Telephone Service is
used, after the services were removed from the control of national post offices.
 The pair of wires from the central switch office to a subscriber’s home was called the
subscriber loop. It was typically powered by 40V(DC) and backed up by a large bank of
batteries in the central office, resulting in continuation of service during most commercial
power outages.
 This 64Kbps service is a bi-directional, or full duplex, voice path with limited frequency
range of 300 to 3400 Hz: in other words, a signal to carry the sound of the human voice
both ways at once. Today, it is also used for internet access via a dial modem, DSL, fax,
credit card terminals, etc.
 Users accessing the Internet with the same twisted pair copper wiring as is used by their
telephone are using a POTS connection. The TCP/IP (transmission control
protocol/Internet protocol) digital data from their computer or LAN (local area network)
is converted to analog format using a modem prior to transmission over the POTS.
The POTS setup has remained virtually the same for decades. There have been many upgrades to
usher components of the POTS telephone system into the digital era, but the copper wire
connection has weathered the storm.
As far as the mechanics of a POTS lines go, this phone service works by establishing a dedicated
circuit between Point A and Point B for the duration of a transmission.
Circuit Switching
Back in the old days, circuit switching was the reason you needed an operator’s assistance when
making calls.
In those days, operators would sit by one giant wooden switchboard, plugging copper wires into
a common patch panel. In the case of connections that required two exchanges, two operators
would go about simultaneously plugging the caller’s and receiver’s wires into the same inter-
exchange wire.
This wire was known as a “trunk”.
Long distance calls were unbearably costly because calling long distance was akin to renting the
use of a very long piece of copper wire each time you wanted to make a call.
Transistors
The transistor heralded the electronic exchange era, which slowly paved the way for the digital
network. Current phone lines have been upgraded to carry digital signals in the form of
“packets.” Packet-based technology does not dominate the transmission channel by demanding a
continuously open and dedicated circuit, unlike its analog counterpart. Rather, it uses the
underlying network to transmit voice (and data) messages independently through the switches. A
copper line is a bi-directional 64Kbps service capable of carrying human voice both ways at the
same time
Modems
This is a device that was designed to exploit the digital nature of the public switched telephone
network without overhauling your entire phone system. This should come as good news for
small business owners who are not planning to upgrade their analog communications systems
any time soon, especially considering the wealth of options available on the market.


ASSESSMENT TEST - I
1. What are the different applications of telemedicine?. (C506.4 PO.1,2)

2. What are the recent advancement in the field of telemedicine?(C506.3, PO 1,2)
Recent Advances
 The first randomised controlled trial of home telenursing showed evidence of its cost
effectiveness
 Electronic referrals are a cheaper and more efficient way to handle outpatients
 General practitioner teleconsulting may be cheaper than traditional consulting in some
circumstances
 Decision support over video links for nurse practitioners dealing with minor injuries is
shown to be effective and safe
 Call centres and online health meet a demand from the public, but are unlikely to be
cheaper for the NHS.
3. Application of ANT in the field of telemedicine. (C506.4, PO 1,2)

4. Write about the satellite and wireless communication in the field of telemedicine (C506.2, PO
1,2)
Wireless Technology
e biosignal sensors are responsible for
acquiring the
physiological data (patient’s vital signs)
and transmitting
it to the signal processing unit. Several
studies are made
focusing only on designing these sensors
to be tiny in
size [], maintain patient mobility [],
and consume low
operating power to reduce battery size
which can last for
longer durations []. A collection of
wearable medical sensors
could communicate using personal area
network or body
network [], which can be even
integrated into user’s clothes
[]. At the next stage, sensor layer of
every remote monitoring
system is typically connected to the
processing device fo
acquiring the
and transmitting
studies are made
to be tiny in
and consume low
which can last for
could communicate
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Telehealth – Wireless Communication -Multipath Propagation
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acquiring the
and transmitting
studies are made
to be tiny in
and consume low
which can last for
could communicate using personal area
network or body
network [], which can be even
integrated into user’s clothes
[]. At the next stage, sensor layer of
every remote monitoring
system is typically connected to the
processing device fo
Telehealth -Signal Propagation
• Propagation in free space is always like light (straight line).
• Receiving power proportional to 1/d² in vacuum – much more in real environments (d = distance
between sender and receiver)
• Receiving power additionally influenced by
– fading (frequency dependent)
– Shadowing (blocking)
– reflection at large obstacles
– refraction depending on the density of a medium
– scattering at small obstacles
– diffraction at edges
Wireless Network Stakeholders

1. Regulatory Authorities
2. The operator or the Service Provider
3. The user or the subscriber
4. Equipment Vendors (network equipment and user device)
5. Research Organizations
Satellite Communication In Telemedicine
Satellite communication in telemedicine is an application of satellites in medicine that resolves the issue of the
lack of professional healthcare in locations where it cannot be originally accessed . A patient can very well be
diagnosed regardless of long distances using telecommunication equipment that enables the health care specialist,
wherever they may be, to interact with the patient and local healthcare giver, thereby, providing almost accurate
diagnosis and treatment to an individual. Satellite communications transmits digital signals at a very high data rate
with low bit error rate . Satellite communication is the transmission of signals from one earth station to a satellite
in space orbiting in the galaxy which will in turn transmit the signals to another earth station .
The frequency bands are the L-Band, S-Band, C-Band, X-Band, Ka-Band and the Ku-Band [1]. For the purpose of
this research, the brief focus will lie on all with the exception of the S and X-BANDS.
Satellite communication has been adopted to allow telemedicine function globally. Telemedicine requires a high
bandwidth transmission for clear and quality digital signals for proper diagnosis and treatments. Satellite
communication has the ability to transmit at high frequencies and long distances, making it better than any other
communication technology that can be used in telemedicine.
VSAT IN TELEMEDICINE
VSAT (Very Small Aperture Terminals) is satellite communication system. As shown in Fig. 1, it comprises of a HUB
station that acts as an earth station for a group of VSATs in a network for transmitting signals to the satellite’s
transponder which will retransmit back to the earth station. VSATs are capable of providing high capacity links to
users providing 35- 45 Mbps internet backbone connectivity [3], [2]. The VSATs in a network are all connected to
each other via the HUB in a star topology network [3]. VSAT provides all the necessary connectivity including
videoconferencing, media streaming, real time video, IP multicast, where it does not necessarily mean that only a
single specialist from a location can interact with an emergency patient but, different health professionals from
different locations can interact with that patient at the same time. It also allows for immediate access to
information via the internet for medical research needed in the communication between doctors and patients in
remote area to the specialists in distant locations.
The concept of VSAT in telemedicine by ISRO (Indian Space Research Organization) consists of an integration of
medical software and computer hardware, medical equipment for cardiology, pathology, imaging and video
conferencing. At each hospital, the VSAT is installed, making it a VSAT network. Detailed information containing
medical history of patients are sent to the medical specialists, then diagnosis, and treatments can be given by
specialists via videoconferencing to the health care professional to carry out on the patient at the other hospital.
THE BENEFITS OF SATELLITE COMMUNICATION IN TELEMEDICINE
Satellite communication is the fastest wireless transmission considering the long distances that signals travel
from earth stations to space with little attenuation and can provide instant internet connection and high definition
quality video streaming in even the most remote locations eradicating the problems of unavailability to medical
attention . Patients in rural areas are more likely to seek medical care if they know it is cheap, safe and reliable . It
allows for telemedicine to be possible in local areas in a cost effective manner since the cost to implement satellite
equipment tools are decreasing constantly.
Data transmission rate is very important in telemedicine and can determine the survival of a sick patient especially
in emergency cases, to which satellite communication can provide it with the speed it needs in its functionality.
This saves a lot of time and money if the specialist needed to come and treat the patient personally because of a
poor speed internet access.
The availability of the satellite transmission is about 99.95% making it possible to for patients to receive medical
health care almost every time and any time of the year .
Satellites transmitting in the C-Band are very reliable and cannot be affected by rainfall, snow, or extremely
terrible conditions. Although, the case of mutual interference exists from terrestrial microwave users . There are
now solutions that converge the Ku-Band and the C-Band frequency bands . With this, telemedicine using the
satellite does not have to be dependent on weather condition.
5. Describe in detail about ISDN in the field of telemedicine ? (C506.2, PO 1,2)
Integrated Services Digital Network (ISDN)

Integrated Services Digital Network (ISDN) ISDN is a dial-up (not dedicated but used on a call-
by call basis) digital connection to the telecommunication carrier. An ISDN line can carry
information at nearly five times the fastest rate achievable using analog modems over POTS
(plain old telephone service).
1980: ISDN Integrated access to all services

Digital end-to-end (Digital subscriber loop)
 One set of interfaces for all services at multiple speeds
 Supports both circuit switching and packet switching
 Out-of-band signaling. Sophisticated network management and maintenance using
Signaling System 7 (SS7)
 Layered protocol architecture
ISDN Channels
B: 64 kbps for data or voice
D: 16 or 64 kbps for signaling or packet switched data
H: 384 kbps (H0), 1536 kbps (H11), 1920 kbps (H12)
ISDN Access Interfaces
Basic Rate Interface (BRI): 2B + D = 2 × 64 + 16 = 144 kbps (192 kbps total)
Primary Rate Interface (PRI): For LANs or PBX

23 B + D = 23 × 64 + 64 = 1.536 Mbps » T1
30 B+ D = 30 × 64 + 64 = 1.984 Mbps = 5H0+D = E1- 64 kbps Framing+mgmt
Functional Groupings
 Terminal Equipment 1 (TE1): ISDN terminal
 Terminal Equipment 2 (TE2): Non-ISDN terminal, e.g., POT
 Terminal Adapter (TA): Allows non-ISDN devices on ISDN
 Network Termination 1 (NT1): Physical layer device. Separates user premises from phone
company. Owned by user in USA. Owned by PTT in many countries.
 Network Termination 2 (NT2): OSI layers 2-3, e.g., PBX, LAN
 Network Termination 1,2 (NT12): NT1 + NT2
NT1:
 Physical and electrical terminal of ISDN at user
 Isolates the user from the transmission technology of the subscriber loop
 Line maintenance functions such as loop back testing and monitoring
 Bit multiplexes various B and D channels m Supports multi-drop lines
 Telephone, personal computer, and alarm on one NT1
NT2:
 Digital PBX, LAN, Terminal controller Switching and concentration
ISDN Reference Points

 Rate (R): Between Non-ISDN and Terminal Adapter. Uses X or V series recommendations.
 System (S): Between ISDN equipment and NT2. Separates user equipment from switching
equipment. Terminal (T): Between NT2 and NT1. Separates network from user.
 User (U): U interface not defined by ITU. Defined in North America since NT owned by user.
ISDN Services Six types of services

 Circuit switched calls over a B or H channel
 Semi-permanent connections over a B or H channel
 Packet switched calls over a B or H channel
 Packet switched calls over a D channel
 Frame relay calls over a B or H channel
 Frame relay calls over a D channel
It is a new set of integrated systems that can integrate many different communication services into a
single digital network capability called the Integrated Services Digital Network. ISDN is specially designed
for transmission of digital data and is about twice as fast as conventional telephone lines. It categorized
into two generations:
Narrow-band ISDN, it uses 64 kb/s and has circuit switching orientation.
Broad-band ISDN, it uses very high data rates and has packet-switching orientation. ISDN is a digital
networking that is necessary to Telemedicine applications. Digitalization and integration of services are
the benefits of ISDN.
ISDN provide greater flexibility. The fundamental objectives of ISDN is that it be based on the telephony
network and gives much better audio quality and much faster data transfer. Future versions of ISDN-
Based Telemedicine system will include facilities for on-line interaction between practitioner and
specialist with simultaneous speech.
(C506.2, PO 1,2,3,4)
Local area network: A local area network (LAN) is a network that connects computers
and devices in a limited geographical area such as home, school, computer laboratory,
office
building, or closely positioned group of buildings. LANs use a network operating system to
provide two-way communications at bit rates in the range of 10 Mbps to 100 Mbps. In
addition to operating in a limited space, LANs are also typically owned, controlled, and
managed by a single person or organization. They also tend to use certain connectivity
technologies, primarily Ethernet and Token Ring.
MERITS
• Cost reductions through sharing of information and databases, resources and network
services.
• Increased information exchange between different departments in an organization, or

between individuals.
• The trend to automate communication and manufacturing process.

DEMERITS
Special security measures are needed to stop users from using programs and data that they
should not have access to;
• Networks are difficult to set up and need to be maintained by skilled technicians.
• If the file server develops a serious fault, all the users are affected, rather than just one user
in the case of a stand-alone machine.
 There are three topologies of LAN Network
Wide Area Network (WAN).
A wide area network, or WAN, spans a large geographical area, often a country or continent. It
contains a collection of machines intended for running user (i.e., application) programs. These
machines are called as hosts. The hosts are connected by a communication subnet, or just subnet
for short. The hosts are owned by the customers (e.g., people's personal computers), whereas the
communication subnet is typically owned and operated by a telephone company or Internet
service provider. The job of the subnet is to carry messages from host to host, just as the
telephone system carries words from speaker to listener.
ADVANTAGES OF WAN
• Covers a large geographical area so long distance businesses can connect on the one network.
• Shares software and resources with connecting workstations.
• Messages can be sent very quickly to anyone else on the network. These messages can have
pictures, sounds, or data included with them.
• Expensive things can be shared by all the computers on the network without having to buy a
different peripheral for each computer.
• Everyone on the network can use the same data.
DISADVANTAGES OF WAN
• Need a good firewall to restrict outsiders from entering and disrupting the network
• Setting up a network can be an expensive, slow and complicated.
• Once set up, maintaining a network is a full-time job which requires network supervisors and
technicians to be employed.
• Security is a real issue when many different people have the ability to use information from
other computers. Protection against hackers and viruses adds more complexity and expense.
Technologies Involved
• Medical Instrumentation
Sensing Bio-medical Signals,
Medical Imaging, Measurement of Physical Parameters e.g. Body Temperature, Pressure etc.
• Telecommunication Technology
Trans-receiver on different communication channels and network such as, on wired network,
wireless medium etc.
• Information Technology
Information representation, storage, retrieval, processing, and presentation.
Write about the history and evolution of telemedicine(C506.1, PO 1,2)

History of Telemedicine
Various forms of telecommunication and information technologies have evolved with time. On
these bases, we can identify four phases of the development of tele-health corresponding to the
use of these technologies (Table-1).
Table – 1: Phases of Tele-health Development

Development phase Approximate time frame
Telegraphy and telephony 1840s-1920s
Radio 1920 onwards till 1950s
Television/space technologies 1950s onwards till 1980s
Digital technologies 1990s onwards
 Clinical or healthcare information over telephone, or broadcasting it over radio stations..
 Marconi’s invention of the radio-telegraph in 1897, which was used during the American
CivilWar to send casualty lists and order supplies.
 1906:ECGTransmission
Einthoven, the father of electrocardiography, first investigated on ECG transmission over
telephone lines in 1906.
 1920s: Help for ships

Telemedicine dates back to the 1920s. During this time, radios were used to link
physicians standing watch at shore stations to assist ships at sea that had medical
emergencies.
 1924: The first exposition of Telecare --- TELEDACTYL

Perhaps it was the cover showed below of "Radio News" magazine from April 1924. The
article even includes a spoof electronic circuit diagram which combined all the gadgets of
the day into this latest marvel! . Hugo Gernsback, predicted that physicians would use not
the telephone, but radio and TV to communicate with patients.
 1955 Telepsychiatry : Closed-circuit television service begun in 1955; used in hospitals

The Nebraska Psychiatric Institute developed a two-way link with Norfolk State Hospital,
112 miles away, in 1964 with further extensions in 1971. This project is one of the first of
many examples of tele-psychiatry.
 1967: Massachusetts General Hospital

This station was established in 1967 to provide occupational health services to airport
employees and to deliver emergency care and medical attention to travelers.
 The National Aeronautics and Space Administration’s (NASA) efforts in tele-health
began in the early 1960s when humans began flying in space. Physiological parameters
were telemetered from both the spacecraft and the space suits during missions.
 1970s: Satellite telemedicine

Via ATS-6 satellites. In these projects, paramedics in remote Alaskan and Canadian
villages were linked with hospitals in distant towns or cities.
 Project STARPAHC - Space Technology Applied to Rural Papago Advanced Health-

Care. STARPAHC aimed at providing medical care to astronauts in space and to the
Papago Indian Reservation in Arizona. This service was carried out through a van that
was equipped with a variety of medical instruments, including electrocardiograph and x-
ray. The van was linked to the Public Health Service hospital and another hospital with
specialists, by a two-way microwave tele-health and audio transmission.
 In the later parts of 1970s, Alaska Satellite Biomedical Demonstration Program and
various other Canadian projects were begun, to serve far-flung areas.
 The first truly international tele-health program, known as Space Bridge, was
implemented by NASA. It was done to provide relief to people after a terrible earthquake
jolted Armenia in 1988 and cased severe devastation.
 The North-West Tele-health Project set up in Queensland, Australia, was the only major
tele-health project outside North America until 1990. This project was designed to serve
rural communities. The project-goals were to provide healthcare to people in five remote
towns, south of the Gulf of Carpentaria.
 This development was followed by Meaningful Use regulation and the Affordable Care
Act in 2010 where Accountable Care Organizations (ACOs) were created to push for the
maturation of telehealth capabilities.
 It’s a fairly obvious statement to say that 2016 was the year of telehealth. Even though
the push for its inception started in late 2014 and showed signs of becoming a real
movement in 2015.
 In 2016, $16 million was given by the federal government to improve access to
healthcare in rural areas. Some of the money was designated for the use of the technology
for veterans and others. While we’re not where many thought we might be, especially
more than 120 years ago, most physicians think the effort is a top priority and will lead to
improved patient outcomes and access to care.
 In 2017, the concept will be unrestricted, paid for and covered, and continue expanding to
a wider audience. For the arguments of telehealth being used to serve the disenfranchised
and the rural poor, telemedicine is set for widespread use.
 There is an expansion of the technology through the use of internet-connected everything

devices and as virtual medical facilities take shape, but there’s been excitement about the
concept before now. Telehealth is likely a real concept now, but even with new
developments, that doesn’t mean all of this can’t be derailed.
The Evolution of Telehealth
One of the landmark publications of the past couple of decades, Crossing the Quality Chasm,
stated, “information technology must play a central role in the redesign of the health care system
if a substantial improvement in quality is to be achieved”. Nowhere is this more true than in rural
communities. New knowledge and new science are being developed all the time. When some
people have access to that new knowledge and expertise and other people do not, disparities
grow. Advances in telecommunication and information technology can help overcome some of
these disparities by redistributing that knowledge and expertise to when and where it is needed.
HOME- AND COMMUNITY-BASED CARE

Health care in the home-based setting has a long history. For example, an 1879 article in the
Lancet talked about using the telephone to reduce unnecessary office visits. In 1925, a cover of
Science and Invention magazine showed a doctor diagnosing a patient by radio, and within
envisioned a device that would allow for the video examination of a patient over distance. Home
monitoring developed more fully in the Mercury space program when the National Aeronautics
and Space Administration (NASA) began performing physiologic monitoring over a distance.
NASA further developed this technology with a pilot with the Papago Indians, the Space
Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project.
The biggest need in home- and community-based care relates to chronic disease. The 100 million
Americans with chronic disease account for about 75 percent of health care expenditures.
Traditionally, chronic disease has been managed through an episodic office-based model rather
than a care management model, which uses frequent patient contact and regular physiologic
measurement. Use of technologies for chronic disease care management has been associated with
reductions in hospitalizations, readmissions, lengths of stay, and costs; improvement in some
physiologic measures; high rates of satisfaction; and better adherence to medication. Studies of
home monitoring programs have shown specific improvements in the management of
hypertension, congestive heart failure, and diabetes.
OFFICE-BASED TELEMEDICINE
Telemedicine has also been used for decades in clinical settings. In 1906, the inventor of the
electrocardiogram published a paper on the telecardiogram. Since the 1920s, the radio has been
used to give medical advice to clinics on ships. Alaska has been a model for the development and
use of telemedicine for decades. For example, community health aides in small villages can
perform otoscopy and audiometry, and the information can be sent to specialists in Anchorage or
Fairbanks to make the determination of whether a patient needs to travel to the specialist for
more definitive treatment. Today, we think of office-based telemedicine as flat-screen, high-
definition units with peripheral devices that can aid in physical examination of the patient. There
are a lot of these units out there, all of which do not talk to each other, and some of which use
proprietary communications methods. If telemedicine is to become as ubiquitous as the
telephone, communications standards will be needed.
Store and forward (S&F), or asynchronous, technologies have been a great advance. For
example, in ophthalmology and optometry, non-mydriatic cameras can be used to perform retinal
screenings in diabetics without needing to dilate the eyes; this has increased screening rates.
Teledentistry has been used to by dental hygienists and dentists to improve access to oral health
care. Dermatology and psychology are two of the biggest areas for telemedicine. Since the
1990s, studies have shown high rates of agreement between diagnoses made in person and
diagnoses made via teledermatology.
ANCILLARY TELEMEDICINE SERVICES

Teleradiology
Teleradiology has been used for at least 60 years. In the past, film was passed through a digitizer;
now most systems use direct digital capture, which allows images to be read overnight in other
countries. Radiologists have promoted the Digital Imaging and Communications in Medicine
(DICOM) standard for transmitting and storing data. By the late 1990s, studies showed that
teleradiology reduced transports for head injuries out of rural areas and that the availability of
teleconsultation with a radiologist significantly affected diagnosis and treatment plans.
Telepathology
Telepathology is less common than teleradiology, but digitization of pathology slides is
becoming much more common. These are very large files, which require the ability to view color
images under different magnifications. A lot of people were concerned about moving these large
files across firewalls, but now a number of models being developed have the image sitting on a
server and the image can be viewed over distance without needing to be moved. Studies have
shown the value of telepathology.
Telepharmacology
Pharmacy has been practiced over distance for a long time. Telepharmacy is facilitated by
computerized physician order entry, remote review, and even remote dispensing. Combining that
with video, being able to review medications, and conducting a video consultation with a patient
allows the whole pharmacy visit to occur over distance. In one recent study on 47 cancer
patients, 27,000 miles of travel were saved because of telepharmacy.
HOSPITAL-BASED TELEMEDICINE
Probably one of the earliest and most famous uses of hospital-based telemedicine was in the late
1950s and early 1960s when a closed-circuit television link was established between the
Nebraska Psychiatric Institute and Norfolk State Hospital for psychiatric consultations. Hospital-
based telemedicine is growing quickly in two areas: stroke care and care in the intensive care
unit (ICU). Evidence shows that with good imaging, high-quality stroke exams can be done over
distance. Although the literature on tele-ICU has been mixed, recent studies indicate associated
reductions in length of stay, mortality, and costs.
A number of devices are being used in inpatient setting as well as in skilled nursing facilities.
Telemedicine reduces avoidable visits to emergency departments for skilled nursing patients.
Some rural skilled nursing facilities exist in communities that do not have physicians, and getting
physicians there urgently can be a challenge.

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DEPARTMENT OF INFORMATION TECHNOLOGY

B.TECH - BATCH (2017-2021): III Year/ V SEM

OMD553- TELEHEALTH TECHNOLOGY (R-2017)

PART A: (3X2=6 Marks)

2. What are the different applications of telemedicine?(C506.1, PO 1,2)

Real-time telehealth applications

PART B: (3X13=39 Marks)

Public Switched Telephone Network System

PSTN Phone Lines Work

Think of a Public Switched Telephone Network (PSTN) as a combination of telephone networks

PSTN – Understanding The Art of Switching

1. The Local Exchange

2. The Tandem Office

3. The Toll Office

This is where any national long-distance switching takes place.

4. The International Gateway

Plain Old Telephone Service

This wire was known as a “trunk”.

 Private hospitals such as Apollo Hospital Group.

Advantages of Telemedicine in India

According to the previous considerations, telemedicine applications in developing countries need

Data Communication Circuits

PAN - Personal Area Network

Plain Old Telephone Service

Plain Old Telephone Service

Wireless Communication Infrastructure-Telehealth

PART C: (1X15 = 15 Marks)

DEPARTMENT OF INFORMATION TECHNOLOGY

OMD553- TELEHEALTH TECHNOLOGY (R-2017)

PART A: (3X2=6 Marks)

2. Store-and-forward or asynchronous Telemedicine

3. Remote patient monitoring (RPM)

3. What are the different applications of telemedicine?.(C506.1 PO.1,2)

• Increased information exchange between different departments in an organization, or

• The trend to automate communication and manufacturing process.

 There are three topologies of LAN Network

Wide Area Network (WAN).

• Shares software and resources with connecting workstations.

• Everyone on the network can use the same data.

• Setting up a network can be an expensive, slow and complicated.

MULTIMEDIA- TEXT, AUDIO, VIDEO, DATA

Multimedia Telemedcine System(MTS)

 Discrete (or Time independent) Media:

Multimedia Telemedicine System – Network Architecture

Continuous Media – Bandwidth

Audio digital telephony 64Kb/s

Video PAL 176Mb/s

Video HDTV 936Mb/s

Types of Telemedicine Information

Table 3. Typical examples of telemedicine information

Source Type Typical file size

Text and Data

Frame Rate and Bandwidth

6. Write about the history and evolution of telemedicine(C506.1, PO 1,2)

Table – 1: Phases of Tele-health Development

 Clinical or healthcare information over telephone, or broadcasting it over radio stations..

 1920s: Help for ships

 1924: The first exposition of Telecare --- TELEDACTYL

 1967: Massachusetts General Hospital