Indian Journal of Medical Informatics. 2008; 3(1): 1

http://ijmi.org

Article

Impact of Awareness of Mobile Internet Technologies on the Healthcare Sector in India

Khamish Malhotra¹ and Stephen Gardner

¹ Coressponding Author

Centre for Electronic Product Engineering,

Faculty of Advanced Technology,

University of Glamorgan, Pontypridd,

CF37 1DL, UK

Phone: +44-7717773864

Abstract

Recent advances in Internet enabled mobile devices have paved the way for remote patient monitoring applications. The aim of this paper is to evaluate the scope and nature of mobile technologies in the healthcare sector on one of the largest countries by population and the fastest growing economy, India. The motivation for the research came from an analysis of the potential benefits Mobile Information Technology could have on large, but often disparate and geographically remote population. Increasing demand for quality services for from a limited resource needs to be matched through massively improved efficiencies in delivery of timely diagnoses and effective treatment. The work presented highlights the possibilities to provide such efficiency gains due, in part, to the awareness of modern ICT (Information and Communication Technologies) systems by young medical practitioners and the ever expanding Mobile Infrastructure in India.

Keywords:

Telemedicine in India; Impact of Wireless Technologies; Practitioner's Views on Telemedicine; Healthcare Survey; Remote Patient Monitoring; Indian Healthcare Sector

Introduction

Mobile Telemedicine is attracting increasing interest in the global healthcare sector and although work has been done in this field in both Europe and the USA, few places in the world could have greater overall gains from such technological improvements than in the Sub-Continent of India. Improvement in the quality of healthcare, and the provision of easy access to practitioners and facilities could enable large numbers of patients to have an early diagnosis and potentially be treated more effectively [1-4]. However, although technology will have a major part to play in any such developments, it is just as important to understand the attitudes and personal prejudices that potential implementers could have towards any such developments. There will have to be a coherent and practical strategy that shows real value to all.

In remote areas, where commuting is a major problem, telemedicine can perform effectively and produce impressive results [6-8]. The adoption of a Telemedicine strategy into the healthcare infrastructure will benefit rural areas, particularly in emerging industrialized countries where distance and lack of clinicians negatively impact the quality of healthcare [6-9]. However, it is clear that system security and data protection will be a key to any proposed architecture [5].

The potential for use of mobile telemedicine in India is clear as it has recently become one of the fastest growing mobile markets in the world after China. Mobile services were commercially launched in August 1995 in India as compared to its launch in China during 1988 [6, 9-10, 14-16] and with more than 650 million people living in rural areas, the potential for benefit is enormous. Remote monitoring of rural population could significantly reduce costs incurred in both traveling and hospital stays, but this will depend on mobile service rollout. Figure 1 gives an indicative coverage map for the New Delhi region.

In most of the metro cities of India GSM/GPRS coverage is quite significant. India's mobile user's base has touched about 143 million with the addition of over 6.8 million subscribers in November 2006 [11]. In the months of July, August and September 2006 almost 54 million new subscribers were added in the 4 metropolitan cities (Delhi, Mumbai, Kolkata, and Chennai) and around 260 million users subscribed to a mobile service in the same months countrywide. Figure 2 represents the complete mobile coverage across India.

Of equal importance is the fact that the cost of connectivity and mobile service rates in India are now among the lowest in the world. From a peak rate of around 50 cents per minute in 2003, mobile tariffs have decreased significantly and now are in the range of about 2 cents per minute [11-12] and this decline in rates is expected to continue.

In order to ascertain attitudes towards the use of mobile technologies some initial research was undertaken via a survey designed in part to evaluate attitudes towards the use of ICT, and in particular telemedicine, by a range of potential users. In order to gauge the attitudes of professionals a questionnaire was sent to 100 healthcare practitioners in Delhi NCR's where mobile coverage is quite significant, as shown in Figure 1. The response rate was not as high as hoped for, but at 41% it still provided some useful, indicative information.

The topics covered in the survey included current telemedicine technology knowledge and usage levels; general attitude towards telemedicine applications; perceived efficacy of telemedicine in enhancing quality of care and intention to eventually use telemedicine. In all, 80% of respondents had some knowledge of the subject but interestingly, doctors of higher seniority had the lowest level of interest in the technology. Young doctors aged 26 years or less were highly tuned into both the technology and the potential benefits, which was a very positive indicator of future uptake and influence on healthcare policy.

The impact of new doctors in the development of a telemedicine infrastructure over the next decade will be substantial as it is these who will be the early adopters of new technologies and will be the next generation opinion formers, forcing radical rethinking and restructuring of many traditional practices.

Remote consultations, measurements and logging of vital signs and the widespread use of integrated networked telemedicine technologies will be a major item on the healthcare agenda for countries with expanding economies as citizens will aspire to new levels of medical care [7, 10, 14-17].

The Survey

The aim of conducting the research survey was to identify the awareness among healthcare professionals of the use of wireless technology for remote patient monitoring. Therefore, the subject groups chosen contained both medical practitioners and medical students. Using a mix of young and experienced doctors provided a varied response due to the diversity of knowledge and the influence of Internet technologies. The research survey was also useful in evaluating some of the important issues of mobile technologies integration within the healthcare sector.

The questionnaire was sent out via email, postal mail and where possible it was also conducted on one to one basis. Participants ranging from senior doctors through to medical students from local surgeries and hospitals were requested to take part in the survey, as shown below.

The questionnaire was designed to ascertain attitudes and knowledge relating to telemedicine and personal anonymity was assured. Themes were developed within the questionnaire to try to identify key areas of concern and evaluation of existing areas of knowledge. The methodology of the questionnaire included a varied selection of techniques including rating, attitudinal questions and closed questions. A number of questions also allowed the participants to provide one or more answers.


Results & Data Analysis

Response Rate

A total of 41 out of 100 questionnaires were returned, giving an overall response rate of 41%, slightly lower than the anticipated rate of 50%. Of the 41 medical professionals who filled out the questionnaire, 19 were between the age of 42-58 years, and 22 were between the age group of 24-28 years, whilst the gender distribution was 54% male and 46% female, which removes any gender bias. Table II indicates to whom the questionnaire was sent and the response rate of each group.

Part of the questionnaire was designed to assess the general understanding of the role of wireless telemedicine of the respondents and the overall effect they felt it would have.

1) To Find the Awareness of Wireless Telemedicine among Healthcare Sector

The respondents were asked to state whether they had heard of remote patient monitoring using wireless technologies or not. 80% of respondents agreed that they were aware and have knowledge about it, whilst 20% did not, as shown in Figure 3.

Figure 4 indicates that 88% of the respondents felt that the healthcare sector was aware of and ready to work with mobile technologies. However, only 10% of the respondents were not in favour and considered it would take some extended time to implement. It was clear that newly qualified doctors were willing to adapt to new ideas and seem to have some prior Information Technology (IT) experience.

Figure 5 reveals that 37 out of 41 respondents (91%) believed that remote patient monitoring using wireless technology would be beneficial for emergency services as well as daily routine check- ups, as it will save time and provide valuable results to the practitioners.

Figure 6 shows that approximately 54% of the respondents felt that all the factors in the healthcare sector are equally important, but significantly 33 out of 41 respondents (80%) agreed that security of patient data was a concerning factor.

Although data security was high on the agenda of the respondents, further answers highlighted
that 51% had no knowledge of the data security issues of the Health Insurance Portability and Accountability Act (HIPPA) and 12% had never heard about it.

3) Awareness of Using Latest Devices in Healthcare Sector

Regarding personal and mobile devices, it was clear that until recently relatively few people knew of PDAs (Personal Digital Assistants) or 3G phones. However, current attitudes indicate that respondents would be happy to use such mobile devices rather than being tied to a Desktop PC to access patient health information.

It can be seen from Figure 9 that although wireless telemedicine is gaining currency in the healthcare industry, only 44% of respondents are already using the Internet to communicate with their patients, with the majority (56%) of respondents still preferring to communicate with their patients on one to one basis.

Conversely, 80% of respondents use either landline or mobile phone to provide consultancy to their patients and unsurprisingly it was the young practitioners who contributed mostly to the 44% of respondents using the Internet as a medium.

4) Adaptation of New Healthcare Technology

Figure 10 shows that only 32% of respondents agreed that patient will not easily accept being remotely monitored by a specialised whilst 58% believed that if patients could be educated as to the benefits they would accept remote monitoring.

5) Cost Effectiveness

More than 75% of respondents projected that remote patient monitoring using mobile technologies will be cost effective in the long term, as shown in figure 11. This belief is re-enforced by their personal experiences of the expansion of mobile technology into everyday life. This factor is quite crucial as it will motivate them to follow the remote patient monitoring applications on a larger

scale. This will lead to the mass introduction of high-end technology into the Indian healthcare sector where cost plays a vital factor.

Figure 12 represents the respondents' opinion about remote patient monitoring being the privilege of the more affluent metropolitan population. 74% of respondents indicated that both urban and rural populations would benefit from this technology whilst 24% feared that it would only be useful to upper class society, considering the cost of implementation. It is quite hard to rule out this notion as practitioners still think that the implementation cost of telemedicine is too high and it can only be borne by the rich.

Fig 13: Factors Affecting Introduction of Remote Patient Monitoring

6) Crucial Factors While Implementing Wireless Technology in the Health Care Sector

The most interesting results were gathered using a question which highlights the factors that will hinder the adoption of the remote patient monitoring application over mobile technologies. Figure 13 represents the most common views relating to the growth of futuristic healthcare sector. Almost 70% of respondents felt that lack of knowledge and understanding of these technologies and the cost factor will be the main issue that could delay the adoption of such technologies. Additionally, 50% of respondents believe that factors such as acceptability by patients or medical staff, difficulty of implementation, technical risks involved and security or performance issues might have some influence on the adoption. Other factors mentioned were medical risk, legalities and personal criticism.

Secure Mobile Healthcare Framework

The background survey clearly indicates that data security and cost were the two most important factors considered as barriers to implementation of remote healthcare in India. There is a requirement that the life-critical data transferred over a mobile medium should have assured integrity and that patient record systems should only be accessed by the authorised practitioners.

Experiments on the architecture shown in figure 14 [2, 19] have shown viable results in terms of security, capital and operational costs. The system on the patient side is accountable for processing and transmitting physiological signals and images from the patient to the practitioner. The practitioner side is responsible for receiving, analysing and displaying the incoming data for monitoring purposes. The incoming data is also stored in the secured database to make better sense of that data thus maintaining complete patient healthcare history. During transmission time all the data needs to be encrypted so as to ensure confidentiality. The integrity of data needs to be provided as well in order to detect any changes in the data or any part of it. All users have to be acknowledged and authenticated in advance to ensure that only persons with relevant access rights (e.g. practitioner) can send and receive messages respectively. This was implemented on a low cost Linux / MySQL based system.

To fulfill these requirements, a cryptographic system satisfying the needs of the mobile users has to be provided. The benefit of cryptographic systems is that they provide integrity check as well as authentication [17-19]. For the encryption and decryption, cryptographic systems involve a mathematical algorithm in combination with a secret key. The usage of a key in addition to an algorithm is necessary, because most of the algorithms are designed to prevent users from reverse scrambling the information without a secret key. Several approaches have been implemented and Elliptic Curve Cryptography (ECC) is emerging as an attractive public-key cryptosystem for mobile/wireless environments. Compared to traditional cryptosystems like RSA, ECC offers equivalent security with smaller key sizes, which results in faster computations; lower power consumption, as well as memory and bandwidth savings [18]. This is especially useful for mobile devices which are typically limited in terms of their CPU, power and network connectivity. In achieving such goals the application of the overall system including mobile technologies, cryptographic methods, security algorithms, and compression techniques will play an important role because of the complexity of the system [19].

Conclusion & Future Work

The results show that most of the medical professionals have some awareness about the wireless telemedicine or the remote patient monitoring application. About 88% of the practitioners agreed that they are ready to get wireless and mobile technology to be integrated in the hospitals and other areas of the healthcare sectors. However there are only 37% of respondents who have heard about HIPAA (Health Insurance Portability and Accountability Act of 1996), which could be a major cause of concern. The survey concludes that 88% of respondents would like the new technology to be implemented in healthcare services but many have limited awareness of the ethical issues. This can be improved by conducting healthcare seminars, conferences on current issues and technologies and continual professional development.

Related research work undertaken by the authors has analysed various important aspects of mobile technologies in the healthcare sector and it is clear that while efficient technological solutions can be created, individual training would be a key requirement [20]. Also, newly qualified doctors, more familiar with this type of technology would be willing to "sell" this type of solution to their patients. Globally, healthcare professionals believe that in the coming years mobile technologies will play a vital role in analysing the well being of patients.

The survey undertaken was mainly centered on what were considered to be the core issues and their effect on the healthcare sector in India. The results of the survey concluded that information security and cost will be the main factors of acceptance but future considerations should focus on value, which will not be a simple parameter to define. The survey also concluded that this technology will eventually be cost effective in the long term with 75% of respondents agreeing that the main benefit of this technology resulted from the ability to undertake routine check-ups of patients from remote specialised doctors. It has also been observed that young doctors were more open to the adoption of new technologies in contrast to those who have been practicing for some years.

References

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Paper received on 22/02/2008; accepted on 18/03/2008

Correspondence:

Khamish Malhotra

Address: Centre for Electronic Product Engineering,

Faculty of Advanced Technology,

University of Glamorgan, Pontypridd,

CF37 1DL, UK

Email: kmalhotr AT glam.ac.uk

This Open Access article is available at: http://ijmi.org/index.php/ijmi/article/view/y08i1a1

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