Pakistan like most of other developing countries is facing problems in addressing the issues of availability of better health care to common man. Developing new hospitals and giving incentives to the doctors to serve at remote communities has not been as successful as needed. Due to dramatic development in the IT scenario of country, Telemedicine is evolving as a possible alternate to address the issue of limited access to health care.
Pakistan – health scenario The Government has been the main provider of healthcare through district and tehsil headquarter hospitals, rural health centers and basic health units. The population of Pakistanis estimated at about 140 million, a major proportion of which resides in rural area. Pakistan is one of the most densely populated countries in the world. However, the number of doctors in the country is not conversant with the number of patients. The doctor to population ratio is 1: 1555 in the country. This makes it difficult to get quick and easy access to medical services. The healthcare infrastructure consists of rural health centers, basic health units, tehsil headquarter hospitals and final referral to district headquarter hospitals and teaching medical institutes. A large chunk of the population of Pakistan, about 75%, lives in rural areas while the percentage of doctors working in rural areas is only about 22%. The ratio of hospital beds is about 18% for the rural areas to nearly 82% for urban areas. As these figures indicate, even though the population of Pakistan is concentrated in the villages and small towns, the medical services in those areas are far from sufficient. To get a hospital under the supervision of experienced doctors, the people of rural areas have no choice but to travel to large cities, incurring expenditure and botheration that is an inevitable consequence of transporting sick patients. This is further compounded by the deficient road network and the low per capita income of average Pakistani. Moreover a doctor sitting at the remote center feels isolated as he doesn’t have any other doctor or a specialist to consult if he faces a problem case or any complication. The remote northern areas of Pakistan are located at a large distance from specialized hospital. The situation is compounded by the difficult terrain of mountains, which severely hampers mobility, access to modern healthcare service, as well as travel cost. A large morbidity rate is a direct consequence of this situation.
Pakistan – a solution The telecommunication industry in Pakistan is undergoing a rapid development, as a result of which the communication connectivity all over the country has improved remarkably. The number of telephone lines in the country is well over three million. Internet has become a popular medium with about a hundred thousand users spanning more than eight hundred cities. These statistics depict the feasibility of the establishment of telemedicine network and its potential contribution to the well being of the citizens of Pakistan.
The population of Pakistan is estimated at about 160 million, a major proportion of which resides in rural area. The doctor to population ratio is 1: 1555 in the country. Even though the population of Pakistan is concentrated in the villages and small towns, the medical services in those areas are far from sufficient. The telecommunication industry in Pakistan is undergoing a rapid development, as a result of which the communication connectivity all over the country has improved remarkably.
Existing Telemedicine Scenario
Role of Elixir Technologies Elixir Technologies is a leading software development company based in USA. Since its founding in 1985, Elixir has been pioneering the development of innovative software for form design, personalized document composition, data extraction, and printstream conversion. Envisioned to contribute to the well being of the people of Pakistan, Elixir Technologies introduced the concept of Telemedicine first time in Pakistan in 1998 in the form of a philanthropic project – TelMedPak. Since then Elixir is sponsoring the project. The organization has done a few pilot projects namely the Taxilla and Gilgit project to assess the applicability of telemedicine and telehealth in Pakistan. The success of these projects showed that telemedicine is not only possible in Pakistan but it can also uplift the health status of the remote areas by provision of the specialist care in areas where conventional face to face consultation with the specialist may not be possible.
Initiatives of TelmedPak
- Taxilla project
To assess the applicability of Telemedicine and Telehealth in Pakistan, a prototype was setup in a private hospital (Ali Family Hospital) located in Taxilla, a small town 20 km from Islamabad. This hospital was equipped with PC having Internet access and a scanner, which was linked to Holy Family Hospital. Methodology used was “Store and Forward Teleconsultation” The hospital was to email case report of patients that required expert medical opinion to send along the case report. Then the concerned specialist was to study these case reports and reply back to the hospital. The complete record of the patients was kept strictly confidential, with limited number of people having access to the records. This project proved its success, thus implying that Telemedicine does have wide ranging implementations in almost very medical specialty.
- Gilgit project
Patients from remote northern areas have to travel more than 16 hours hard drive to the capital in search of specialized health care facility. Gilgit with a population of 250 thousand people having limited health facilities and severe climatic conditions is the ideal place where telemedicine can help the population by reducing the travel time and cost to the patient.
Patients suffering from specific diseases are mostly looked after by the doctors who are not trained in that particular specialty and have no choice of discussion and second opinion with senior colleagues.
TelMedPak during its project in Gilgit, aimed at creating awareness among the population and sensitizing the policy makers about this easy solution to the health situation. A practical model of telemedicine was demonstrated by contacting the DHQ Gilgit with surgical unit Holy Family Hospital, Rawalpindi, where General surgeons, orthopedics, medical specialists were made available.
Various practical modalities of telemedicine were tested like sending the data about cold cases and getting the consultation, doing live chat, discussing the trauma and other intensive care patients with senior colleagues and involving voice chat among panel of doctors on both sides. Transferred data included digital photographs of the patient as well as scanned images of the relevant information like x-rays, E.C.Gs, CT scans and lab reports.
- Telemedicine centers in upper Punjab
After pilot projects, four cities of upper Punjab were identified and remote telemedicine centers were established there.
- Pindi Gheb
- Gujar Khan
- Fateh Jang
The doctors from these areas (Gujar khan, Pindi Gheb, Fateh Jhang and Jhand) were trained in telemedicine initially and then they are involved in teleconsultations by serving at their own remote sites. These centers are providing the expert medical advises to patients coming to the centers utilizing their telemedicine set up.
- Taxilla project
- Telemedicine Studies
- Web based Teleconsultations
One of many features of the TelMedPak web site is a FREE Teleconsultation Clinic online with the name of “Ask A DOC”. It is available at telmedpak.com/askadoc
It uses simple store and forward technology User asking for a medical advice has to send his query via the online form. The query is then forwarded to the consultant of the concerned specialty who answers the query within 48 hours. Emergency queries are responded within 24 hours. Uptil now about four hundred queries have been responded with an average of about seventeen queries a month. Gynaecoly, obstetrics’ and medicine are the mostly consulted specialties.
- Teledermatology Study
To compare the accuracy of store and forward method of teledermatology with the traditional face-to-face consultation a study was conducted from the TelMedPak platform. The comparison was done between Institute of Dermatology King Edward Medical College Lahore that served as teledermatology center and Dermatology Department of Pakistan Institute of Medical Sciences Islamabad from where patients were selected. Telmedpak provided the technical support. Thirty three patients were selected from outpatient department of PIMS and images were taken using a digital camera. Images were stored in computer and were sent to Institute of Dermatology via email for Teleconsultation along with a short history and examination findings. Diagnosis of consultant after face-to-face consultation was then compared with the image based diagnosis that is after teleconsultation.
- Training of Paramedical Staff
LHV’s and TBA’s were educated through TelMedPak’s continued medical education Program via on line courses. In this way knowledge of paramedics and medical staff working in the remote areas was updated for the welfare of target population.
- Telemedicine Training Manual
Keeping in consideration the computer literacy of Medical staff, TelMedPak has devised Telemedicine training manual which includes basic computer skills, IT concepts, Telemedicine concepts and working. Doctors from the remote areas are being trained with this manual.
The Elixir Technologies is committed to be the main private sector organization to support telemedicine. All the telemedicine projects of TelMedPak have been the core of telemedicine activities of Pakistan.
- Web based Teleconsultations
Role of Government of Pakistan
- Establishment of Telemedicine Forum
The Ministry of Science and Technology realizing the potential of telemedicine in Pakistan has established National Telemedicine Forum in September 2001 with the objective to oversee and drive the development and collaboration of IT and medicine with particular reference to Telemedicine. The main aim of creating the telemedicine forum was to create awareness about telemedicine in the country by arranging seminars and conferences at National level, which will not only encompass the medical arena but also focus the IT, Telecommunication community and the general public at large. National Telemedicine conference 2002 was organized by the forum on June 22nd ,2002. The conference not only successfully created a lot of hype about telemedicine in medical and IT community but also got a lot of exposure from the media. The conference was one if its kind as it demonstrated live telemedicine session for the first time in Pakistan, showing actual teleconsults between the doctor and the specialist and also between the patient and the specialist. Live Telesurgery operation was also shown in the conference with the use of Fiber optic technology.
- Identification of Telemedicine Projects
One of the objectives of the forum was to identify pilot projects, which can then be replicated at national level. Project for Development of Health Management Information System (HMIS) has lead to establishment of electronic patient record system at federal hospital. Another project is Development of Health Information Resource Center (HIRC) which aims at promoting health research and link research to development. It will be an online resource center about medical journals, medical research activities and database of hospitals and doctors of Pakistan. Through this online center not only the doctors will be benefited but the general public will also be able to get a lot of useful information.
Initiatives of Pakistan Space Organization
The Pakistan Space and Upper Atmosphere Research Commission (SUPARCO) is the country’s national space agency. It is responsible for the execution of the space science and technology programs in the country, as approved by the Government of Pakistan. SUPARCO is an autonomous R&D organization under the Federal Government.
The national space programme, which is being executed by the national space agency, SUPARCO, is basically aimed at furthering research in space science and allied fields, enhancing indigenous capabilities in space technology and promoting the peaceful applications of space science and technology for the socio-economic development of the country.
SUPARCO is engaged in a fairly comprehensive and wide ranging space research and applications programme. The programme encompasses various pertinent fields of space science and technology and related discipline areas.
SUPARCO has launched Pakistan’s First Satellite based telemedicine network. It has connected JPMC hospital in Karachi with remote medical center at Shikarpur for patient Evaluation and consultation. This network has been established in Sindh province. The next step is development of satellite based telemedicine centers at holy family hospital, Rawalpindi in Punjab province and primary care centers in Muzaffarabad keeping in view the geographical isolation of northern areas and the role which space technology can play in these health care inaccessible areas.
Pak-US Collaboration in Telemedicine
- Telemedicine Training of Pakistani Doctors
Pak-US collaboration in Science and Technology fields led to the opportunity of training of two Pakistani doctors in USA. These doctors were sent to the US to get trained from the US telemedicine experts at the best telemedicine centers in the world. These doctors are acting as master trainers in the country and hence building a human resource in this particular field. Virginia commonswealth university, Richmond is running a telemedicine program with holy family hospital Rawalpindi focusing on use of technology in decision making and exchange of expertise.
- Telemedicine / e-health Training Project
The Telemedicine training of two Pakistani doctors at TATRC, USA had an objective that they can train more people in Pakistan. Telemedicine/E-health training center was established at Holy Family Hospital, Rawalpindi to train medical staff of the region in telemedicine applications. This was a joint collaboration between ministries of science and technology Pakistan and USA. The project was a six months’ pilot in which a model training center was established in Holy Family Hospital and connected to a remote telemedicine center in a rural area. This has acted as a training ground for telemedicine training of doctors and nurses. In the initial phase 45 doctors and nurses from Rawalpindi region have been trained. In the second phase medical staff from all over the country will be trained in telemedicine applications.
Telemedicine Association of Pakistan (TAP)
Telemedicine association of Pakistan has been established to oversee the campaign and future projects of Telemedicine in Pakistan. The major contributions of telemedicine Association of Pakistan in past one year include:
- Role in Disaster management
TAP has taken the responsibility to set up telemedicine in quake stricken areas in AJK and NWFP for disaster management.
Setting of telemedicine centers
- Hub at Holy Family Hospital
- Five centers in NWFP including one in Ayub Teaching hospital
- Eight centers in AJK
- Two centers in referral step down hospitals
Each center was equipped with telemedicine hard ware including Note book, Web camera, Inmarsat Satellite phones and connectivity. These centers were established in existing relief hospitals. The Medical staff got consultation about the earthquake victims from consultants at the hub.
- Training of Volunteers in Telemedicine consultations
- Students from IT Universities
- Medical Students
- Doctors at the remote field hospitals
These volunteers were trained in setting up of telemedicine satellite units and seeking Teleconsultations through short duration workshops at Telemedicine/E-health training center, Surgical Unit II, Holy Family Hospital, Rawalpindi. These short duration training workshops enabled them to Configure Inmarsat to Notebooks and get satellite connectivity, to use telemedicine software and to facilitate the existing medical staff to get Teleconsultations from the consultants at the hub.
- SETUPS MADE BY TAP
- Telemedicine setup at Hattian Bala, AJK.
Telemedicine facility has been provided at Hattian Bala field hospital setup by Bilal Hospital and operated by Cuban doctors and nurses. Cuban government has generously sent more than one thousand doctors and nurses to quake-hit areas. These medical teams have worked tirelessly in the remotest of the areas.
- Telemedicine activities in Muzaffarabad
The telemedicine team for disaster relief carried out the telemedicine training session at Abbas Medical Center, Muzaffarabad to the local IT experts and students. The idea was to have local human resource this field so that their expertise can be utilized for providing medical relief through telemedicine. Field Hospitals from various other countries and organizations are working in devastated areas. Our mobile telemedicine team has provided telemedicine consultation facilities on need bases. Turkish field hospital in Muzaffarabad is one such Hospital.
- 4th Asia Pacific Telecommunity workshop in Rawalpindi Pakistan.
4th Asia Pacific Telecommunity workshop held in Rawalpindi, Pakistan in jan 2006. This was jointly organized by International telecommunication union, Tokai university, Japan and Telemedicine.
- Collaboration with Regional and International Telemedicine Teams
Telemedicine Association of Pakistan and Telemedicine Training center are working in close collaboration with regional and international telemedicine organistaions. These include Sanjay Gandhi Institute of Postgraduate medical sciences India, Tokai University Japan, University of Calgury Canada, Telemedicine and Advanced Technology Research Center (TATRC) and Virginia Commonwealth University (VCU), USA.
- Telemedicine setup at Hattian Bala, AJK.