" (Doukas, Maglogiannis and Kormentzas, 2006) The following illustration shows the evaluation Platform Architecture. Figure 3

The Evaluation Platform Architecture

Doukas, Maglogiannis and Kormentzas (2006) state that the patient state vital signs are monitored through a PDA device attached to the patient and transmitted to a computer for evaluation through wireless access or Bluetooth. Additionally the patient site is monitored through use of a camera. The software that has been developed is used to monitor the patient status as well as the network status and determines the proper coding of the data collected on the patient. Doukas, Maglogiannis and Kormentzas states that two patient states have been identified as (1) normal; and (2) urgent. (2006) Sensors used to monitor patient data include those of: (1) ECG, BP (non-invasive blood pressure); (2) PR (Pulse Rate); (3) HR (Heart Rate) and (3) Sp02 (Hemoglobin Oxygen Saturation). (Doukas, Maglogiannis and Kormentzas, 2006) The following illustration lists the data level thresholds which indicate the status of patients.

Figure 4

Patient Data Coding According to Network Quality and Patient Status

When patient status is normal there is no transmission of real time data unless otherwise ordered by the physicians. Information containing vital signs average values are included in daily status reports. In the event of an emergency it is stated that "the real time data transmission mode is activated, alerting the monitoring physicians regarding the patient status and allowing thus efficient remote care (e.g., medication advise, urgent patient transfer to hospital, etc.)." (Doukas, Maglogiannis and Kormentzas, 2006)

The work of Kodandaram (2009) entitled: "Telemedicine: Healthcare for the Future" states that many countries including the country of India are short of 600,000 doctors, 1 million nurses, and 200,000 dental surgeons to achieve 1:10,000 doctor-patient ratio." (Kodandaram, 2009) It is reported that 72% of India's population still live in rural locations, 75% are dispensaries, and 60% of hospitals are located in urban areas. However, the government of India reports having launched a national health insurance scheme and one in which the home clinic has been integrated. States is that the idea of being treated from one's home is "very comforting and is proving to be cost effective." (Kodandaram, 2009)

This idea is driven by the aging population of India and the increased demand in remote locations as well as by advancing technology with forecast to reach $18 billion by 2015. It is stated to telemedicine will soon play a role that is important. The different forms and uses of telemedicine are based on the type of service:

(1) Teleradiology: Provides primary diagnosis of medical images such as x-ray technology; (2) Teleconsultation: General practice consultation through an audio-video conference and exchange of patient information for routine chronic disease management like diabetes, high blood pressure, etc.) non-emergency review, and prescription refills;

(3) Telecardiology: Observation of a chronic heart patient through monitoring of blood pressure, electrocardiograms (ECG), pulse, etc.;

(4) A cardiologist can review the data and advice on the condition and initiate any emergency care if required; (5) Teledermatology: Remote diagnosis of a patient's skin condition;

(6) Teleophthalmology: Remote ophthalmology consultations and diagnosis of various eye conditions;

(7) Telepathology: Viewing laboratory specimens located at a remote laboratory through a camera-based microscope. (Kodandaram, 2009) Sensor drives used in telemedicine application include such as "...temperature sensors, blood pressure monitors, weighing machines, pulse oximeter (SPO2), ECG, etc."

Kodandaram (2009) states that a key requirement for consideration in telemedicine is the consideration of the need to provide a telecommunication technology that is both "reliable and cheap." (Broadband installations are reported to have grown and government and non-government organizations are stated to be "taking the lead by sponsoring satellite links."

Kodandaram (2009) states that bandwidth availability is "not a big challenge for other telemedicine disciplines involving images. Today, bandwidth availability is"... not a big challenge for other telemedicine disciplines involving images. To transfer patient information to the hospital server, applications have to be HL7 (health level seven) compliant. Being HL7 compliant, patient health records can be electronically maintained (electronic medical record -- EMR). It also allows for sharing of patient data across hospitals and systems, allowing interoperability of applications and systems. In addition, telemedicine solutions should allow for billing and connection to insurance systems. Under the RSBY healthcare scheme, the government has mandated that every person who is availing of the RSBY facility be issued a smart card that would track his/her vital...

Through the smart card, the insurance company can track utilization of the insurance coverage for billing." (Kodandaram, 2009)
Stated as another key consideration in the implementation of telemedicine is the deployment of solutions that are in compliance with the Health Industry Portability and Accountability Act (HIPAA) and that properly address "security and privacy issues of health records." (Kodandaram, 2009) According to Kodandaram "...this would mean that patient data has to be secure while at rest (stored in the telemedicine box) and while on the move (transmitted from box to a server or doctor). For images to be stored or transferred to the hospital server or doctor's office, the boxes also should be DICOM (digital image and communication) compliant. " (Kodandaram, 2009)

The equipment used should be very user friendly because making a technician available at remote locations is not stated to be feasible. Broadband width availability is stated to be needed for "dynamic data throttling" requirements in telecommunication initiatives because there is more to telemedicine than simple image transmission.

Interoperability and standards compliance requirements relate that adoption of standards such as HL7, DICOM and HIPAA become more prevalent in developing countries and that telemedicine equipment should "allow for upgrades without additional investment. Integration and interoperability between existing hospital applications could be a challenge." (Kodandaram, 2009) In regards to billing and accounting for the healthcare service it is stated that the integration of "government scheme and payment to service providers and hospitals could be a challenge." (Kodandaram, 2009) The telemedicine solution is stated to comprise of "a PC for Internet connectivity and data transfer, a web camera for video, an aggregator box to take sensor inputs, and a telephone for audio."

Kodandaram states that the telemedicine platform known as 'MindTree' is a single integrated aggregator box solution" and that a "variety of sensor devices can be connected to the box through the available USB or serial ports." (2009) Also reported to be integrated into the box are audio and video conferencing facility and Internet connectivity. This solution is one that is integrated and one that "enables the solution provider to configure the telemedicine setup with different sensors and interface devices based on the actual need of the community, thereby significantly reducing cost. It offers multiple variations of the platform. Variants can have smart card readers to address the RSBY requirement, built-in LCD/external monitor/TV, and Bluetooth connectivity. The solution also supports HL7, DICOM and HIPAA standards." (Kodandaram, 2009)

The platform is stated to be designed on a "...standard SoC which supports two processor cores -- an ARM core for application software and a DSP core for signal processing. The solution used open source software components to keep the product cost low. Application management is based on Linux operating system (OS). H.264 compression is used for video, which is an excellent choice as it enables more effective video compression than older standards. H.264 provides better flexibility for applications to operate in a wide variety of network environments, particularly considering the different use case scenarios of the telemedicine solution. Video is transmitted to the remote side using common intermediate format (CIF), which allows to easily convert to PAL or NTSC format. Also, depending on the available bandwidth, the application is able to throttle and tune the number of frames sent per second. The image type can be changed to quarter CIF (QCIF) if required. The DSP core in the SoC is used for audio and video conferencing and data processing requirements. The telemedicine solution employs G.711 for audio compression. This is a simple and effective compression algorithm that is used in telephony applications." (Kodandaram, 2009)

The telemedicine platform, through host the application and platform on a Linux OS "has the advantage of connecting the hardware directly to any IP (Internet Protocol) port without having to worry about porting the TCP/IP protocol stack to the embedded platform. Linux also gives us lot of flexibility in implementing application Graphical User Interface (GUI) using any of the open GUI frameworks. The platform is also designed to support online firmware/application upgrades. This feature is helpful when new medical standards are evolving, as it eliminates the need for a technician to visit the field and allows easier software maintenance. The platform handles close to 3,000 patient records. This is adequate for a community of people in a small village. The solution has been realized with low-cost memory devices and interfaces, allowing for optional higher memory size. Patient records are stored as EMRs so as to enable transfer of data to a remote server located at hospitals or data centers. Patient EMR and usage information can be uploaded…