Nimhans' new facility to heal ailing

urban minds

BENGALURU: If all goes according to plan, the city will be home to another
campus of the National Institute of Mental Health and Neuro Sciences
(Nimhans) within a year. With a focus on urban healthcare, the centre will
leverage technology to benefit patients.

The campus, which will come up on 39 acres of land near Krishnarajapuram

in east Bengaluru, hopes to cater to an urban population of 50 lakh. Nimhans
has collaborated with private practitioners, volunteers from private hospitals,
doctors from primary health centres and teachers, who have been trained as
counsellors. Nimhans director Dr BN Gangadhar told TOI: "The government
had given us 39 acres of land two years ago, on which we would like to set up
a digital facility. It will make use of telehealth system, through which patients
can consult the psychiatrist or counsellor over the telephone if they can't visit
the facility. "The centre will have a digital database of patients' medical history
, enabling the doctors to constantly monitor their health".

Apart from psychiatrists, the facility will include yoga experts and meditation
specialists. Not only will it provide treatment but also rehabilitate patients and
impart vocational training to them to help their families. It will be a
comprehensive programme, added Gangadhar.

After initiating the rural district mental health programme in 1985 in Ballary,
Nimhans is planning to turn its focus on the urban populace, which deals with
a completely different set of problems. "A big city is a melting pot of cultures.
Sometimes, people from other states with different cultures feel out of place
and isolated in another city . Heavy traffic congestion, high pollution levels and
a disturbed sleep (often experienced by those working graveyard shifts) are
major causes of stress which irritate urban minds. Drug and cyber abuse have
made it necessary to have a set-up in place which caters to urban needs,"
said Gangadhar.

With litigation on, the director expects the centre to be ready in a year.
TIMES VIEW

Living in a metropolis may have its perks but it comes with a fair share of
problems -stress is the most common and there's no escaping it. Along with
stress comes anxiety related disorders which can be managed with timely
help. The centre proposed by Nimhans aims to do just that by tapping
technology. Mental illness is still taboo, with few willing to visit a psychiatrist.
The tele health facility will give such patients the option of voicing their
concerns over the phone without having to come face to face with a doctor.
Engaging the patients in activities like yoga and meditation will help calm
troubled minds and hopefully lead to healing

TELEHEALTH CENTRE

he Princess Alexandra Hospital Telehealth Centre is a telehealth facility for PAH staff.
The centre, opened in 2012, provides a range of health outreach services to patients in
rural and remote Queensland using telehealth technology.

It provides fully equipped clinical consultation rooms, meeting spaces and private
studios for clinical consultations. The centre aims to:

 Facilitate the integration of telehealth into routine practice by engaging with all
clinical services at the PA Hospital.
 Increase the volume of telehealth activity generated through the PA Hospital.
 Deliver a broad range of health services to rural and remote hospitals throughout
Queensland.
 Reduce the need for patients to travel to Brisbane by substituting some face-to-
face consultations with telehealth appointments.
 Provide professional support to clinicians in remote locations by
videoconference.
 Reduce specialist travel by combining telehealth with existing outreach
program.

World's First Facility Dedicated to Telehealth

Described as a “hospital without beds,” the Virtual Care Center is home to a large medical team, but
no patients. Using highly sensitive two-way cameras, online-enabled instruments and real-time vital
signs, clinicians “see” patients where they are. That may be in one of Mercy’s traditional hospitals, a
physician office or in some cases, the patient’s home.

The new four-story facility is the nerve center for telehealth programs, including:
Mercy SafeWatch – Launched in 2006, it’s the largest single-hub electronic intensive care unit (ICU)
in the nation. Doctors and nurses monitor patients’ vital signs and provide a second set of eyes to
bedside caregivers in 30 ICUs across five states.
Telestroke – Many community emergency departments (EDs) across the country don’t have a
neurologist onsite. With Mercy’s telestroke program, patients who come to the ED with symptoms of
a stroke can be seen immediately by a neurologist via a two-way audio and video connection.
Virtual Hospitalists – A team of doctors is dedicated to seeing patients within the hospital around-
the-clock using virtual care technology. They can order needed tests or read results, resulting in
quicker care.
Home Monitoring – Mercy provides continuous monitoring for more than 3,800 patients, intervening
quickly when needed. This reduces the patients’ need for hospitalization and helps them live
independently longer.
Mercy’s Virtual Care Center is also designed to be a workspace for developing innovations in patient
care, plus training and product testing.

Indizium commissioned a state-of-the-art Audio Visual and Telemedicine (AVT) centre. The AVT centre
involved the setting up of a Command Control Centre (CCC), linking it to various centres of excellence around
the world, the 10 operation theatres within the Hospital as well as link ups to the Teleconsultation Room,
Training Room, Visitors Lounge and the nearby Kuala Lumpur Convention Centre. The AVT centre consists
of the following interconnected areas

TELEMEDICINE COMMAND CONTROL CENTRE

As the hub for the entire AVT centre, all video, audio and telecommunication networks will converge here. It
will also have capabilities to monitor and control activities and equipments in other parts of the centre. The
Auditorium will function as a start of the art conference centre where major medical related meetings,
conferences and video conferencing sessions can be held.

SMART SURGICAL SUITES

These Smart Surgical Suites will act as digital operating suites capable of cutting-edge, minimally-invasive
robotic surgery, audio, videoconferencing and digital imaging and video display, under Indizium’s proprietary
Smart Operating Control System. SOCS brings voice, video and data to a centralized point where they can be
controlled and routed using a touch panel interface. In addition, all video, audio and data can also be routed to
remote locations for teleconsultation or distance learning purposes

Indizium India
Indizium India
S-332 Lower Ground Floor
Greater Kailash-2
New Delhi-110048
India

Contact Number
(O) +91 11 29221092

the remote diagnosis and treatment of patients by means of telecommunications

technology.

Design firm helps Mercy virtual care center

to meet its goals
Virtual care center delivers high-tech environment for staff to collaborate and connect with
nature
November 19, 2015
Distinctive for its high-tech method of delivering comprehensive health care from one
remote site, the new $54 million Mercy Virtual Care Center, Chesterfield, Mo., is
designed to foster collaboration in a flexible space that also keeps its staff connected to
nature.

From all indications, it has delivered on the objectives. The 125,000-sq. ft., four-story
facility integrates telemedicine technology with a multidisciplinary clinical team, the
availability of electronic health record data in real time and the ability to utilize advanced
algorithms to detect patients who need immediate intervention.

The virtual care center houses the technology and clinicians for three major programs
including Mercy SafeWatch, ConnectNow and CareEngage. ConnectNow links patients
and providers with online-enabled instruments to perform medical exams and view test
results. SafeWatch provides 24-hour patient monitoring using video, audio or online-
enabled medical devices. CareMatters analytics tools and technologies help providers
manage current and future patient health needs.

Obviously, that level and type of care requires a special facility. Mercy and design firm
Forum Studio/Clayco, St. Louis, collaborated closely to design and build what the health
care system believes will transform patient care delivery, says Matthew Hanis, senior
vice president for business development, Mercy.

“From the ground up, the building is built to support a mission of the integration of faith,
our goal to innovate and be entrepreneurial, and to transform the care process and the
importance of serving our patients and our co-workers,” Hanis says.

Rectangular, 30,000-sq. ft. floor plates are designed to optimize flexibility and
accommodate future programs and technology. Circular meeting rooms with large-
screen monitors foster innovation, an important element that Mercy wanted to
incorporate within the facility, says Tyler Meyr, associate principal and lead designer,
Forum Studio.

The flexibility factor is evident on the top floor with its movable white board walls and
massive video board that is 7 feet high by 35 feet long. The setup accommodates the
need for staff interaction within and outside Mercy’s system, says David Hirschbuehler,
AIA, LEED AP BD+C, associate principal and institutional core group leader, Forum
Studio.

The space allows teams of innovators to collaborate both internally and externally
through the use of interactive video technology and advanced analytics, he says.

“So, it’s not just on the patient interaction side, but it’s also the professional side of
Mercy where you can have some great collaborative spaces,” Meyr adds.
The second floor houses pods made of noise-dampening fabric where as many as 160
clinicians can monitor patients around the clock, in a sense making it the nerve center of
the facility. The third floor is shell space for future growth.

The center features floor-to-ceiling glass windows that offer views of the site and
accommodate natural daylighting. The glass strategically undulates to create entry
locations and balconies on upper floors, which allow occupants to step outside and view
nature surrounding the facility.

“The facility’s design reinforces a core design concept of connecting the interior with the
exterior and allowing the outside to enter the building to provide a meaningful impact on
the physical, emotional and psychological environment,” Hirschbuehler says.

The facility is located among tall, mature-growth trees that were retained to preserve the
natural setting of native plants and foliage.

Making the facility as resilient as possible was important after Mercy’s hospital in nearby
Joplin, Mo., was destroyed by a tornado on May 24, 2011. An enhanced window system
featuring laminated glass and safe zones inside the facility offer protection for staff if
severe weather threatens, Hirschbuehler says.

The new center already has generated interest from several leading health care
systems in the United States and visitors leave impressed with the center and the work
being done, Hanis says.

“There’s a universal reaction that what we’re doing is so incredibly transformative we

probably couldn’t be able to do it without a space like this,” he says.

Telerehabilitation is a term used to describe the provision of rehabilitation services at a distance

using telecommunications technology as the service delivery medium1. It is a subgroup of
telehealth which is an umbrella term denoting all health care services, whether clinical or
educational, which are delivered via telecommunications means. Telerehabilitation relates to the
services delivered by a number of health disciplines including physiotherapy, speech pathology,
occupational therapy, biomedical engineering and others and features all aspects of patient care
including the patient interview, physical assessment and diagnosis, treatment, maintenance
activities, consultation, education and training. The term telerehabilitation has become relative
ubiquitous within the rehabilitation sciences disciplines, however there are exceptions such as
the adoption of the term “telepractice” by the American Speech-LanguageHearing Association in
20012. Conceptually, telerehabilitation is an alternate mode of service delivery of traditional
rehabilitation services and should not be thought of as a new rehabilitation service in its own
right. As such, the practice of telerehabilitation does not remove or alter any existing
responsibilities for the provider of the rehabilitation service and providers must adhere to
existing ethical codes of conduct, scope of practice, state and federal laws and individual
discipline policies guiding practice. This document is concerned primarily with the provision of
physiotherapy services at a distance via telecommunications technologies and therefore the use
of the term telerehabilitation will be used to denote the delivery of professionalphysiotherapy
services at a distance. History Telehealth services and practices have arguably been around for
the better part of a century. Telerehabilitation, however is a remarkably new field which was
fundamentally “created” in 1997 by the National Institute on Disability and Rehabilitation
Research (U.S. Department of Education) who proposed a new Rehabilitation Engineering
Research Center (RERC) in the area of so called “tele-rehabilitation.”3 The slow uptake of
technology in the rehabilitation field is due to many factors. The need to often physically touch
the patient for assessment and treatment purposes, and the need to objectively measure the
physical performance of clients both present significant technical challenges for the developers
of telerehabilitation technologies. These factors have surely contributed to the languid
development of telerehabilitation services and technologies and only in the past decade or so
with the development of more complex optical and sensor based technologies have these barriers
started to erode. Driving factors The primary thrust behind the development of telerehabilitation
services is the aspiration to provide equitable access to rehabilitation services, regardless of a
client’s physical location. This is of major concern in Australia where, despite an increase in
health expenditure in recent years, a lack of access to high quality health services for all remains
4; 5; 6. Access to rehabilitation services may be limited by a variety of factors including:
physical distance from health facilities, a physical impairment preventing or restricting
attendance at a local service, a lack of clinicians or specialists in a geographic area, lack of
transportation, or the inadequate provision of resources in a geographical region. Contributing
significantly to this problem in Australia is the significant difficulty in the recruitment and
retention of rehabilitation professionals in non-metropolitan centers and rural and remote areas7.
The provision of a service that is accessible in the home, can be delivered from any location
(including metropolitan areas), is flexible and is equally therapeutic presents as an elegant
solution to address these service delivery issues. A number of other factors also present as
advantages for telerehabilitation services. These include: (1) www.physiotherapy.asn.au 2 of 4
the potential transportation cost and time savings from the perspective of both the health care
system and the patient; (2) the continuity of patient care that can be achieved through the remote
provision of services; (3) the heightened ability to control the timing, intensity and sequencing of
the intervention; (4) the potential environmental impacts of reducing travel; and (5) other
benefits such as the positive effects of rehabilitating a patient in their own social and vocational
environment. Telerehabilitation activity Telerehabilitation applications have emerged using
various technologies such as the videophone, hardware videoconferencing systems, personal
computer (PC) based videoconferencing systems with dedicated software tools, sensors
technologies and expensive, fully immersive virtual reality systems with and without patient
feedback. Broadly speaking, the technologies used for telerehabilitation can be classified as:
image-based telerehabilitation; sensor based telerehabilitation; and virtual environments and
virtual reality telerehabilitation. Image based technologies, such as those that employ
videoconferencing, have the longest history in telerehabilitation and have been used in
telerehabilitation research since the early 1990’s8. There is a growing body of research to
demonstrate that image based technologies can be successfully used for the remote diagnosis and
management of clients and these technologies present as the most effective means for
physiotherapists to provide services at a distance. This has led to the use of these technologies
for routine client care in a number of public health service districts in Australia. Sensor based
telerehabilitation utilizes sensor technologies such as tilt switches, accelerometers and
gyroscopes to sample and quantify movement through three-dimensional space. Although
considerable progress has been made in the interpretation of biosignals to produce clinically
relevant information, it is surprising to note that there have been few attempts to integrate this
information with telecommunication technologies for the remote measurement and rehabilitation
of clients. This is likely to be an area of rapid development over the next few years. Virtual
reality (VR) based telerehabilitation systems make use of configurable computer-generated
three-dimensional virtual environments to elicit specific movement and motor responses by the
client. The virtual environment can be displayed to the client via computer screen or fully
immersive environments are possible with the use of head-mounted visual displays and haptic
feedback devices. Physiotherapists are able to manipulate these environments to incorporate key
rehabilitation concepts such as task repetition, feedback and motivation which have been
demonstrated to result in the learning of new motor skills which translate to the real world. As
computational power increases and the cost of technology decreases, home based VR systems for
the remote rehabilitation of patients is an attractive concept that warrants further research.
Considerations Telerehabilitation presents as a tool that may offer significant benefits to the
physiotherapy profession, however a number of barriers and issues must be addressed before
these technologies become an integral part of rehabilitation health care. 1. The traditional
physiotherapy approach involves significant physical contact between the therapist and the
patient making it difficult for some treatments to be applied online. A conceptual shift in
thinking and a willingness to adapt some approaches will be required for the successful
integration of telerehabilitation. 2. State-based registration presents as a significant barrier to
telerehabilitation practice as practitioners are currently required to be registered in the state in
which the patient resides. Remote consultations crossing state lines can be financially onerous
due to the cost of initial application fees, annual renewal fees, and the need to satisfy the state’s
educational requirements9. Progressing to a national registration scheme would ameliorate this
issue in Australia. www.physiotherapy.asn.au 3 of 4 3. The current lack of comprehensive
training for professionals in telerehabilitation applications constitutes a barrier to the inclusion of
this service delivery model in health care. The future of telerehabilitation will depend on training
at the undergraduate and postgraduate level in the appropriate use of technologies for
telerehabilitation practice. 4. Many patients accessing rehabilitation services demonstrate
significant levels of disability, particularly those requiring neuro-ehabilitation. The greater the
level of disability (physical, cognitive, and communication), the more difficult it becomes to
conduct a rehabilitation consult online. Adaptive technologies may yet need to be developed to
facilitate telerehabilitation with these clients. 5. Reimbursement for telerehabilitation services is
limited in health care systems throughout the world and remains one of the most significant
barriers to the expansion of telerehabilitation in the private sector. Ongoing negotiation with
insurers with the backing of efficacy research is required to ensure telerehabilitation services are
financially feasible for providers. 6. In the age of evidence based practice, further research is
required to crystallize the evidence base for telerehabilitation practice. Such research is critical to
fuel the acceptance of these practices by professional, government, and health funding bodies.
Clinical research is needed to set minimal technical specifications and standards, validate clinical
protocols, investigate the effectiveness of clinical interventions, report client and clinician
satisfaction, and establish the cost-effectiveness of telerehabilitation. With the maturation of
telerehabilitation technologies, and the rapid increase in the speed and quality of the
telecommunication solutions they rely upon, we are entering an age where telerehabilitation
consultations are not only feasible, but can be very effective in the remote management of
clients. In response, several rehabilitation professions in the United States and Canada have
recently drafted position statements for their members addressing issues such as clinical
standards, ethics, professional licensing, liability and malpractice, privacy and confidentiality,
and reimbursement10; 11. Such steps seem prudent to ensure that high quality physiotherapy
services are ensured in the digital age. CIC direction Support the development a set of clinical
guidelines outlining minimal technical specifications and standards, clinical protocols,
considerations and responsibilities be produced for use by the APA membership Training
services, resources and materials be developed to address the educational requirements of the
membership The CIC recommends that the APA engage in discussion with insurers regarding
reimbursement for telerehabilitation services in Australia The CIC recommends that the APA
encourage and support telerehabilitation research by its members Organizational Response In
line with many other professional bodies, the CIC recommends the APA produce a policy
statement regarding the use of telerehabilitation technologies by its members

Telemedicine is an emerging field in healthcare arising out of the synergistic

convergence of Information Technology with Medical Science having enormous
potential in meeting the challenges of healthcare delivery to rural and remote areas
besides several other applications in education, training and management in health
sector. It may be as simple as two health professionals discussing medical
problems of a patient and seeking advice over a simple telephone to as complex as
transmission of electronic medical records of clinical information, diagnostic tests
such as E.C.G., radiological images etc. and carrying out real time interactive
medical video conference with the help of IT based hardware and software, video-
conference using broadband telecommunication media provided by satellite and
terrestrial network. Telemedicine in India is at a nascent stage and AIIMS has
taken a lead to take it to higher glory.

Applications :
1. Tele-health care: It is the use of information and communication technology
for prevention, promotion and to provide health care facilities across distance.
It can be divided in the following activities
- Teleconsultation
- Telefollow-up

2. Tele-education: Tele-Education should be understood as the development of

the process of distance education (regulated or unregulated), based on the use
of information and telecommunication technologies, that make interactive,
flexible and accessible learning possible for any potential recipient.
 Definition

There are several definitions of telemedicine. According to World Health

Organisation, telemedicine is defined as, “The delivery of healthcare services,
where distance is a critical factor, by all healthcare professionals using
information and communication technologies for the exchange of valid information
for diagnosis, treatment and prevention of disease and injuries, research and
evaluation, and for continuing education of healthcare providers, all in the
interests of advancing the health of individuals and their communities”.

Programs
At present the Facility has the following Programs :
1. PAN – African e-network with 54 countries of the African Union.
2. SAARC Telemedicine Project with 6 SAARC countries.
3. In-house Telemedicine link with Rural Hospital at Ballabhgarh in Haryana.
4. Link with 54 centres in India and also abroad.

How to set up a telemedicine

practice
AUTHOR
Meg Bryant

PUBLISHED
Jan. 5, 2017

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As more hospitals move from fee-for-service to value-based payment models that

reward providers for keeping costs low, telemedicine offers a valuable tool for
achieving that goal. Smartphones are everywhere, internet connections are faster
and consumers are eager to engage with doctors on their own time from the
convenience of their home or office. According to the American Telemedicine
Association, more than 15 million Americans receive some kind of remote medical
care, and that number was expected to grow by 30% in 2016.

Health systems are also primed to offer telemedicine services. Expanded access to
primary and specialty providers, reduced emergency room visits and inpatient
hospitalizations, and improved care coordination among a patient’s providers are
some of the benefits telemedicine can provide.

Telehealth technology company American Well already has more than 50 health
system partnerships. Among those that sealed the deal last year were New York
Presbyterian, Bon Secours, and Baptist Health South Florida.

However, setting up a successful telemedicine practice requires serious planning

and fitting a lot of disparate pieces into the healthcare puzzle. The SAMHSA-HRSA
Center for Integrated Health Solutions developed a resource guide on starting and
sustaining a telemedicine practice. Topics covered include what services to provide,
billing and reimbursement, and policy guidelines and considerations.

Sarah Sossong, director of the Center for Telehealth at Massachusetts General

Hospital, offers seven useful steps in planning and setting up a telemedicine
practice.

1. Align the hospital’s approach to telemedicine with a specific strategy. Is the aim to
increase, access? Improve patient outcomes? Attract consumers? Reduce cost?
Expand reach?
2. Select appropriate telemedicine solutions (video visits, e-visits, second option,
etc.) to attain that goal.
3. Identify the site of care (outpatient, inpatient, ER, etc.), pain points and goals for the
telemedicine practice.
4. Establish a structure to support the practice.
5. Take time to ramp up each specialty regarding operations, legal and regulatory
issues and the technological aspects of the practice — software and hardware,
training and systems integration.
6. Determine how telehealth practitioners will get paid. Will it be through some sort of
grant funding? Institutional reimbursement? Patient self-pay? Contract? Or public
and private payers?
7. Align to the regulatory and reimbursement environment (licensure, credentialing,
practice standards, etc.) in the state or states the organization serves.

Another thing organizations need to consider is whether they should go it alone or

partner with an established telemedicine company. Hospitals with limited resources
to commit to telehealth and a short timeline to get the practice up and running may
see a partnership as a way to address those issues. Vendor demonstrations and
partnerships can also help an organization better refine what they are interested i n
achieving through a telehealth practice, Sossong says.

If a hospital does decide to partner, they should consider the capabilities of the
different vendors carefully, she adds. “Partnerships don’t minimize the need for an
 internal dedicated lead, or team, but they can definitely help you achieve your goal
more quickly, though at a cost. The cost of building internal infrastructure can also
be significant depending upon your goal,” she says.

Despite enthusiasm for telemedicine, there are some concerns. Telehealth is

governed by a patchwork of state regulations, which can be hard to sort out.
Interoperability of electronic health records and questions about privacy and
security are other potential concerns.

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Some physicians may not be comfortable conducting a virtual patient exam, making
a diagnosis or presenting a treatment plan without a face-to-face visit. The Texas
Medical Board recently began requiring that physicians meet with patients in person
prior to providing telemedicine services, which prompted telemedicine company
Teladoc to file a lawsuit challenging the rule. This could limit when and how the
services are used.

There are also technological costs and challenges. Telehealth services require
special software, which in turn require training and support. If either the software or
hardware fails during a doctor-patient encounter, the session ends without resolving
the health issue that prompted it.

“While there are pros and cons to providing a telemedicine service, I don’t think it’s
something that healthcare providers will long have a choice about,” Sossong tells
Healthcare Dive. “Telemedicine services are becoming an expectation of
consumers. In the same way that I expect that my bank will allow me to deposit
checks via a mobile app without going into a brink and mortar facility, consumers
will expect that appropriate telemedicine services will be provided by their
healthcare provider, and paid for via insurance in the same way that appropriate
face-to-face services are paid for.”

What kind of return on investment can organizations expect from a telehealth

practice? “The ROI to be achieved depends upon your strategy, you solution and
your goals,” Sossong says. Aligned with a population health management strategy,
ROI could be improved patient engagement, patient outcomes and/or access to
care. It could also be reduced costs via fewer readmissions or emergency room
visits.

Recommended Reading:

 Healthcare DiveHealth systems lining up to offer telehealth options

http://www.virtually-
anywhere.net/tour/mercy/mercyvirtual?startscene=scene_Front_Entrance