Here are some materials that our team has put together regarding telemedicine in rural Nepal:
the winning open architecture design (architects will be out to achham in October): http://www.openarchitecturenetwork.org/challenge/asia
our clarifying brief for the architects of that competition, provides pertinent details:
http://www.nyayahealth.org/Library/OAN_AMD_Nyaya_Health_ClarifyingBrief.pdf
our winning telemedicine entry in the Yale Entrepreneurial Society Y50K Competition:
http://nyayahealth.org/Library/YaleY50KPlanFINAL.pdf
Unpublished brief on telemedicine for non-physician providers:
http://www.nyayahealth.org/Library/AlmaAta_DigitalEra.pdf
our powerpoint overview:
http://www.nyayahealth.org/Library/Stanford_Presentation.ppt
Various Articles and Links Regarding Project:
Article in Economist on the limits of leapfrogging technologies (e.g., most ICTs) and the need for "medium-level" technological infrastructure (in our case, trained doctors and adequate medical supplies).
http://www.nextbillion.net/newsroom/2008/02/11/the-limits-of-leapfrogging
Learnings from IT and Health Seminar at NYU Wagner School of Public Service
It was about "Role of Information and Communication Technology in Rural Development" by a NYU faculty Laxminarayan Subramanian http://cs.nyu.edu/~lakshmi/. and http://ictfordevelopingregions.blogspot.com/. It was very interesting about how he has been developing very cost effective solutions for rural settings and in the field of telemedicine. I will write about the main points that will be related to us and our work.
1.
Drive-by wifi technology - one of the interesting way of keeping track of a medical database from a rural place. This project is called united villages (
www.unitedvillages.com, http://www.firstmilesolutions.com/) They use a daily bus to transfer data from the rural site to the city. the bus carries a small hard drive connected with a router and a small operating sys which has a sync software. as soon as the bus reaches the range in the city, data is automatically synced in with the main server. when the bus leaves for the village, the new data to be sent to the village is downloaded to the hard drive and the same thing happens when the bus reaches the village wifi range.
Pros - easy to install and one router and a single bus can be used.
Con - we stay very far from kathmandu and the travel time from Achham to KTM or nepalgunj is very long. we could think of using it for a server at dhangari but the bus services are not that reliable.
2.
Wildnet WIFI system - This is a really a fantastic technology. It uses a standard industrial grade router board with flash drive (2 GB which has a operating sys in it) and then another 512MB card for the software which will run the router. it also has an antennae attached to it. the softare is an open source and is used to disable all the other work of the router card and is used to boost the signal.
http://www.engadget.com/2007/03/27/intel-developing
-software-hack-for-long-range
-wifi/. this way they have shown the signal transmission upto 400km. the speed ranged from 5-10MBPS. with more advanced hardware speed could be reached upto 54Mbps. All the cost of this one node was $500. We can arrange the same router settings in a mesh and setup a mesh network with satellite centers. It was tested in the high hills of venezuala and in the hills of kerala.
Pros - Very useful considering the cost and the long distance range. we could have a node at bayalgada and another at silgadhi and another at nepalgunj. we have broadband services at nepalgunj and we should not depend on sending the signal to KTM. if the elevation and other things work out we can send the signal directly to Kathmandu. using intermittent towers.
considering the bandwidth and the cost, i think it is very cheap and effective compared to the satellite based system. and we have to pay for the bandwidth of the Internet from the ISP only which is very cheap compared to the satellite based bandwidth.
Cons - i am not sure if we can use wifi at sanfe where our first services will be. I still have not got any answers on how to boost the CDMA signal that we have at bayalgada. I have no idea about the legal issue of using the Long Range wifi but i have seen it work and get praised as done in
http://www.nepalwireless.net/ so it should not be that problematic to work out. We should really do some brainstorming about this option. Niraj can give more idea about the working of these kind of system.
Another similar system is used in Dharamshala in Himanchal Pradesh of India.
http://drupal.airjaldi.com/ it is much cheaper around $300. this is really similar to the nepali wireless project .
3. Long range WIFI and telemedicine - they were using similar kind of long range wifi in India in aravind eye hospital (
http://www.aravind.org/) where they treat over 2 million patients every year. they have many outpost manned by a nurse and a computer technician. patients get real time advice from the specialist at the main hospital visa long range WiFi based video conferencing.
http://www.aravind.org/Telemedicine/index.htm . a more detail description of the network is at
http://www.aravind.org/Telemedicine/atnnetwork.htm . We don't need this kind of extensive networking right away but i think we can start with the basic connectivity.
4. programmable cellphone system - this is a really radical idea. they are using cellphone with a software which will have a highly secure cryptographic ID system which is unique for each owner. this phone is then used to connect to the ATM in the village or the market. this will have an offline authentication system which means that the ATM will be loaded with the ID of all the bank users in the area. they have further developed the system where they have divided the total bank balance of the customer to the mostly used ATMs. Suppose a customer has Rs 10000 in the bank then the system will accommodate so as to the person can withdraw up to 4000 from an ATM which he often uses. this can be customized according to the customers wish. this will have another advantage. lets say a business owner has an ATM which is like 50m away and he uses this one for almost all of his transaction. then the limit of the with drawls are set on a high limit for this costumer. this way he can run his business more effectively.
5. SMS loan repayment. bank uses a single person as the loan repayment collection officer in a village. both the customer and the officer, an owner of a local grocery store, have an unique ID which is encoded in the 160 characters of the SMS. then suppose the customer wants to repay 1000 to the bank he sends an SMS to the bank saying that he is giving the money to the shopkeeper. now after receiving the money from the customer, the shopkeeper sends another confirmation SMS to the bank which says that he has received the money. then the bank sends a secure receipt to both the person stating that the deposit is complete. the bank sends another representative to collect the money in either weekly or monthly basis.
6. Adherence by SMS -
http://www.emedonline.com/ they are using these kind of reminder softwares based on RFID and SMS system to find the adherence and other related data in regards to medication. they are trying to use it in monitoring the drug adherence with HAART.
Links to projects, organizations
[http://www.medialabasia.in/healthcare.html|http://www.medialabasia.in/healthcare.html]
http://globalmedicalknowledge.org/
http://www.bmj.com/cgi/content/full/323/7312/524?ck=nck
http://www.bmj.com/cgi/content/full/323/7312/524?ck=nck
Software Applications
iPath (http://ipath.ch/site) is an association that provides the software and networking capabalities for telemedicine forums, in which doctors or other members, such as community health workers, can share medical images and information for the purpose of aiding diagnoses, prognoses, etc. This is an association that is driven from the bottom up, as its functioning capacity relies on the contribution of its members. This is consistent with the community health worker program's goals, which include the CHWs conveying information in addition to receiving it from trained physicians.
PathoPic is a public access image databasae (http://alf3.urz.unibas.ch/pathopic/e/intro.htm), whose high quality images are classified according to topography, stain, diagnosis, and other characteristics. Whereas iPath is meant to aid in patient treatment, PathoPic is only intended for instructional purposes. This could serve as a useful tool for training community health workers. The photos for this database come from various universities and medical institutes; as such, this is more of a top down intitiative, though useful nonetheless.
AccessGate is a Radio Access Network (RAN) that optimizes bandwidth and enables more cost-effective wireless operations via reduced backhaul bandwidth. It requires two site systems: a cell site system, which converges mobile traffic onto a common narrowband or IP/Ethernet backhaul in conjunction with the Mobile Switching Center (second system) that terminates these various connections. The optimizers are issued in pairs: one at a base transceiver station and another at a base station controller or radio network controller. This device operates in adverse environmental conditions but is mainly designed to improve already existing connections, often IP-enabled VSATs (very small aperture terminals). For more information, http://www.nmscommunications.com/NR/rdonlyres/F22606DA-62E3-4235-9835-2EBDE85038D1/0/AccessGate.pdf.
Standard videoconferencing via ISDN requires an optimal bandwidth of 384 kbit/s.
Although this is not consistent with the long-term goals of receiving information from as well as contribting to the global medical community, in the meantime, all that is required to receive medical information, such as in the case of a primary health worker having difficulty making a diagnosis, is a digital camera and a computer capable of sending images to Swinfen Charitable Trust, an organization that employs medical specialists to offer medical advice.
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