Delivering Subspecialty Health Care to Rural I di India using the Mobile Phone i g th M bil Ph ‐ The Narayana Nethralaya Experience in Tele ‐ Ophthalmology Dr Anand Vinekar MS FRCS(UK) FPVR (USA) PGDM (H MS, FRCS(UK), FPVR (USA), PGDM (Hosp) ) Head, Dept of Pediatric Retina & Pediatric Tele ‐ Ophthalmology, Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India National Broadband Initiative APRIL 16 th 2010. New Delhi
Why ‘Subspecialty Care’ ? Why Subspecialty Care ? • 74% Rural Population 74% Rural Population • Inadequate health care delivery services – d h l h d li i Primary Health Care (PHC) & Community Health Care (CHC). Limited private enterprise H l h C (CHC) Li i d i i • “Experts” in few large cities – NO access to the rural masses
Fields in Medicine that rely on Image Based Diagnosis d i i Dependence on S pecialty Images Dermatology 70% (need to touch and feel) Radiology 80% Ophthalmology > 90%
Number of Inhabitants / Doctor 10 000 People / 10,000 People / Cardiologist 100,000 People / Ophthalmologist
Population: 1.2 billion Population: 1.2 billion Doctor: Population ratio 59:100,000 (GOI,2001) Vitreo ‐ Retinal Surgeons : 340 (VRSI membership,2008) g ( p, ) Pediatric Retina Specialists : < 15
Tele ‐ Ophthalmology – Narayana Nethralaya Experience h l i • Retinopathy of et opat y o Prematurity • Largest cause of g infant blindness in developed countries • India is suffering from the “Third Epidemic” h “ hi d id i ”
Tele ‐ Ophthalmology – Narayana Nethralaya Experience h l i • Affects Preterm & Affects Preterm & Low Birth Babies (< 2000 g) ( g) • 47% of Infants (< 1750) 47% of Infants (< 1750) suffer from “some ROP” • 15% of these will turn BLIND if not treated
• Blindness Preventable if Detected “On Time” and timely treatment is given • Problem: < 350 Qualified Retinal Surgeons in India • 2 million babies born < 2000 grams every year
Every two hours 3 infants reach Every two hours 3 infants reach threshold for treatment in India* * Extrapolation based on GOI Data (2007) and PGI, Chandigarh, NICU Incidence
Narayana Nethralaya KIDROP Trial KIDROP Trial (Karnataka State Internet Assisted Diagnosis of ROP) g ) 2007 to date
Narayana Nethralaya T i l T S Triple T Strategy Initiative Initiative • T ele ‐ ROP T • T rain peripheral ophthalmologists (ROP fello ship) (ROP fellowship) • T lki • T alking to and Training t d T i i pediatricians & gynecologists gy g
Transporting Equipment to the Periphery Transporting Equipment to the Periphery
Day District Distance Districts Covered Thus Far Districts Covered Thus Far (Kms) (Kms) Mandya, Mon 320 Mysore, y Chamrajnagar Bangalore Tue 50 BBMP BBMP Tumkur dist Wed 220, Hosur (TN) 80 Kolar Thu 152 Tumkur Fri Fri 141 141 Pavagada Bangalore Sat 68 Urban Sun ‐ ‐
RETCAM IMAGING IN THE PERIPHERAL NICU NICU Technicians Trained to image, save, retrieve and analyze the images The images are uploaded to the website for remote “Readers” Technician may become Technician may become the ‘first point of health care” for the infant and mother
Technician’s Decision Algorithm – Both eyes imaged* * Algorithm was developed with Clare Gilbert, UK in 2008
Capturing 360 degree ORA SERRATA
Fresh Hemorrhage from the ridge Asymmetry of Stages in two eyes Comparing Images between TWO sessions to aid diagnosis
Characteristics of a good “Tele” Tool Characteristics of a good Tele Tool • “Loss ‐ Less” transfer of images – real time g • Mobility : PC based or Mobile Phone? • Quick to install, Easy to use and SECURE • Disease specific templates • Multiple consults – teaching and training
Peripheral Centre: Uploader User Interface ABO Compression ABO Compression Technology: Headquarters: Headquarters: Viewer User Interface
I mage Review
1908 infants: 14 months : 18 Centres: 350 km radius No of babies Birth Weight Period of screened (grams) Gestation (weeks) 387 TOWN (M) 1322 31.1 TOWN (MA) 146 RURAL 1 (A) RURAL 1 (A) 1496 1496 32.9 32.9 442 RURAL 2 (K) 1366 31.6 199 RURAL 3 (T) 1502 32.9 436 URBAN 1 1198 30.1 (MSR) 298 URBAN 2,3 (P) 1298 31.0
30 26 25 23 20 15 Screened Lasered 10 8 5 1 0 Ist Quarter Ist Quarter 2nd Quarter 2nd Quarter
Expansion Expansion • NRHM – Narayana Nethralaya PPP for 6 more districts • Since September 2009 – Si S b 2009 Three batches, ongoing • Expansion to other states • Thailand, Kenya, Ghana, Bhutan, Srilanka
Estimated ROP Case Load Sl. 6 C No. Populatio No. Deliver No. of ROPs of ROPs Cost of No category of n of ies Premature/ col no. 7 requiring ROP District Taluk PHCs (08 ‐ 09) LBW (50%) treatment treatment s deliveries (15%) (@ Rs. (10%) 4000/case) 1 2 3 4 5 6 7 8 9 10 1 Bidar 5 1740031 41 34228 3423 1712 257 1028000 2 Gulburga 10 3660387 108 81199 8120 4060 609 2436000 3 Raichur 5 1969521 43 34544 3454 1727 259 1036000 4 Koppal 4 1401644 47 21589 2159 1080 162 648000 5 5 Bij Bijapur 5 5 2061418 2061418 63 63 43168 43168 4317 4317 2158 2158 323 323 1292000 1292000 6 Bagalkot 6 1896918 46 37242 3724 1862 280 1120000 Total 35 348 178890 25197 12599 1890 7560000
Ophthalmology Times – Europe, p , October 2009 “… A possible model for middle income countries.” – OT, Europe … A possible model for middle income countries. OT, Europe
Tele PACS • Efficient workflow • Compare prior studies for progressive disease evaluation Ophthamic Ophthalmic Remote Reporting 4 4 1 1 2 2 3 3 TelePACS TelePACS Camera Camera Vi Viewing i Modules M d l Server PC Ophthalmic Worklist Secure WEB Download Upload Progressive Planned Viewing Ophthalmic Viewer OR • Lossless iPhone compression • Encrypted • Secured Ophthalmic Ophthalmic Worklist Viewer
Remote Viewing Ophthalmic Ophthalmic Camera ANY SITE TelePACS Server PATIENT SITE ANYWHERE Progressive Viewing Upload Progressive Viewing Ophthalmic p Worklist & Viewer • Stores Studies for Stores Studies for •Studies captured by St di t d b • Remote Ophthalmologist R t O hth l l i t • Creates reports via WEB C t t i WEB download. digital Fundus logs-in at the Server over reporting feature or Word • Provides user camera WEB. upload. services over the •Uploader installed • Downloads viewer one time • Electronically signs and WEB such as: on Fundus camera from server. sends to Patient Site or • Viewer download Vi d l d workstation • Downloads worklist from forwards to consultant . • Worklist creation •Uploader encrypts, server. • Workflow compresses • Selects studies to download management. losslessly and from the worklist. • Admin functions transmits Studies transmits Studies • Downloads studies realtime • Downloads studies realtime • User to Server over LAN and progressively views authentication or WAN • Uses Viewer tools to analyze images.
iPhone Log-In Screenshots Your institution here here Home screen of hospital or clinic
iPhone Worklist List of studies for History of Visits for Patient Information review Particular Patient
iPhone Viewer Screenshots Image with Compare Thumbnails Images
iPhone Reporting Flow
PC vs Cell Phone Remote Image Viewing PC Based PC Based Mobile Phone Mobile Phone Internet Required Network – 2G, 3G Variable speeds – rural areas Better coverage Less Mobility Less Mobility Anywhere Anytime Anywhere, Anytime Resolution – better? Improving – “Nearly As Good” ‐ validation lid i Size Convenient – Pocket size
Wireless Market Evolution Today 4G /LTE 4G /LTE 3G 3G Wide-Band Digital Cellular Cellular 2.5G 2.5G � Video Wide-Band � High-end Digital gaming Cellular Digital Digital � ~100 Mbps � ~100 Mbps 2G 2G 2G 2G � Video Cellular � 10msec � 300kbps- � Voice � Flexible 14Mbps bandwidth � Email Digital 1G 1G Cellular � Photos � Voice � Web � ~100kbps � Pager Analog data Cellular � 10kbps data � Voice only � Voice only
6 Sing a different tune 6. Sing a different tune iPhone used to stave off blindness Who would have thought that the pricey Apple iPhone could help India's rural masses? But doctors at the Narayana Nethralaya doctors at the Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, are doing precisely that to diagnose vision loss in infants from remote areas. Over 8 per cent of India's 27 million infants each year per cent of India s 27 million infants each year weigh less than 2 kg and run the risk of Retinopathy of Prematurity. So long just a handful of city doctors had the know-how. Now with the iPhone and a software developed by with the iPhone and a software developed by the i2i TeleSolutions, the good doctors are busy saving lives across the country.
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