National Telemedicine Network Initiatives & State Projects Overview

PAN INDIA TELEMEDICINE NETWORK E E- -Health Division Health Division Health & Family Welfare Ministry Ministry o of f Health & Family Welfare 1

Current Scenario NATIONAL TELEMEDICINE NETWORK (NTN) MoHFW issued Guidelines to States Support to States/UTs for Telemedicine under NHM PIP Various States like Rajasthan, Uttar Pradesh, Maharashtra, Punjab etc. implemented Telemedicine services Support provided to 8 States with Rs. 253 Crores in 3 financial years TELEMEDICINE GUIDELINES FOR HWCs Guidelines are framed to act as the BaseDocument for proposals by States Provided framework for infrastructure, manpower, implementation methodology and model to be adopted by States Proposed Interoperable Telemedicine solution with integrated diagnostic devices States are being supported under NHM based on the proposals submitted for Telemedicine in HWCs. 2

Observations on State owned Telemedicine Projects S.No. State E-Health Observations 1 Rajasthan Telemedicine Project (100 Centres) PPP Mode Glocal Telemedicine services as implementation agency 100 Centers on Rental Model Call Centre setup at Jaipur ~Rs. 26000 per month per centre 30587 consultations from June 17 to March 18 Per Consultation Cost is Rs. 850 2 Himachal Telemedicine Project (25 Centres) PPP Mode Pirmala Swasthya care as implementation agency Call Centre setup at Solan 23488 consultations till March 2018 Overall Per Consultation Cost is approx. Rs. 750 3 Himachal Telemedicine Project (2 Centres Kaza & Keylong) PPP Mode Apollo healthcare as implementation agency Call Centre setup at Chennai 20342 Consultations till March 2018 Overall Per Consultation Cost is more than Rs. 1500

Observations on State owned Telemedicine Projects S.No. State E-Health Observations 4 Maharashtra Telemedicine PPP Mode Consultation from 6 Government Medical Colleges Total Expenditure since 2006 : 792.68 Lakhs 1.85 Lakh consultations till March 2018 Per Consultation Cost is Rs. 425 5 Jharkhand PPP mode Apollo healthcare as Private Partner Call Centre based consultation CAPEX per Centre is Rs. 70,000 Per Centre Cost per Month is quoted as Rs. 85,564 Estimated cost per consultation is Rs. 270 (provided 20 consultation per centre per day)

States supported by NHM Total Allocation (Lakh) Total 2015-16 2016-17 2017-18 2018-19 Expenditur e (Lakh) Funds Approv ed Expendit ure Funds Approved Expendit ure Funds Approved Expendi ture Tripura 594.72 565.49 707.76 547.76 593.71 103.18 211.14 2107.33 1216.43 Andhra Pradesh 262.08 91.02 436.8 898.73 10298.73 4985.00 NIL 10997.61 5974.75 Himachal Pradesh 37.5 220.52 244 207.96 233.67 89.03 236.39 751.56 517.51 Maharashtra 397.85 338.69 411.55 340.38 310.29 113.61 275.9 1395.59 792.68 Punjab 68.42 51.6 68.42 56.32 0.00 24.01 63.12* 136.84 131.93 Rajasthan NIL NIL 1000.00 NIL NIL 125.00 NIL 1000.00 125.00 Bihar NIL NIL NIL NIL 200.00 NIL NIL 200.00 0.00 U.P. NIL NIL NIL NIL NIL NIL 7289 7289 0.00 Jharkhand NIL NIL NIL NIL NIL NIL 1424 1424 0.00 West Bengal NIL NIL NIL NIL NIL NIL 310.80* NIL N/A 5 * Proposals under examination Total 25301.93 8758.30

Problem Statements States Telemedicine are operational under Public Private Partnership Mode (PPP) No skill development of Government Doctors Limited ownership by State Administration in operations Consultation Services provided by Private Partners from their own Call Centre setup No interoperability of EHR Telemedicine services implemented as Pilot projects not covering whole State Few States covered all DH but real need is at CHC/PHC/SC 6

Pan India Telemedicine concept Hub and Spoke model to be adopted State Medical Colleges/District Hospitals shall be upgraded as HUB for providing Doctors/Specialist and Super-Specialty consultation to spokes DH/SDH/CHC/PHC/SC The spokes shall be upgraded with required infrastructure for conducting the Tele-medicine session with doctors/specialists at HUBs There will be 3 layered structure for Telemedicine services : Layer : I HUBs at Medical College/District Hospital (Doctors/Specialist consultation) Layer: II Spoke @DH/CHC/PHC (interlinked with HUBs for specialist consultation) Layer: III - Spoke @SC (Connect to PHC or HUB for General/ Specialist consultation) e-Sanjeevani Telemedicine application developed by CDAC Mohali will be implemented uniformly in health facilities The existing manpower at spokes shall be trained to use the system e-Sanjeevani Dashboard will be integrated with HWCs master Dashboard Earmarked Premier Govt. institutions as HUBs with States for HWCs (click for info)

Requirements from State Existing Infrastructure under NHM Scheme to be utilized or upgraded New Infrastructure to be provisioned after Gap Assessment by State State to opt for following Server deployment methodology : Option: I Servers could be located in State Data Centre (SDC) Option: II The State may host in a Central Cloud Location To start with., a 5 seater (MBBS doctors) Call Centre to be provisioned for every 100 Spokes Proposed 3 specialities are Cardiology/Gynaecology/Pediatrics to start with State to propose their own requirement on additional speciality Specialist doctors to be hired on Daywise Remuneration basis only. State to finalize the specialities and remuneration. Budgetary provision to be made in PIP. 8

High Level Architecture HUB (MC/DH) Specialist Doctors stationed at HUB. Only referred patients from 1st level MBBS Doctors at HUB for 1st level of consultation and creation of EHR Video Consultation SPOKES/ HEALTH AND WELLNESS CENTRES CHC/PHC Sub Centre 9

Implementation Timeline S.No. Activity Timelines (Days) 1 Approval of proposal in PIP T 2 T+10 Video Conference with MD (NHM) AS&MD as Chair (to demonstrate Software + finalizing HUB location) 3 Procurement of equipment at Spokes (Desktop + Printer) T + 30 (from GeM) 4 Setting up of HUB (Site preparation + Desktop + furniture) T + 45 (from GeM) 5 Recruitment of MBBS Doctors + Specialists T + 60 6 Handholding on e-Sanjeevani Application by CDAC (To be initiated by State) T + 30 7 Training to staff (in-person training) (if required) T + 45 8 Go-Live of Project T + 60 10

Infrastructure requirement Matrix Facility Type IT Infra Network Human Resource Medical College HUB Desktop (with camera, Mic) 4 mbps per Desktop Nodal Officer MBBS Doctors Specialists District Hospital HUB Desktop (with camera, Mic) 4 mbps per Desktop Nodal Officer MBBS Doctors Specialists District Hospital Spoke Desktop (with camera, Mic) Diagnostic Device (optional) Printer 4 mbps per Desktop MBBS Doctor CHC Spoke Desktop (with camera, Mic) Diagnostic Device (optional) Printer 2 mbps per Desktop MBBS Doctor PHC Spoke Desktop (with camera, Mic) Diagnostic Device (optional) Printer 2 mbps per Desktop MBBS Doctor Sub Centre Spoke Desktop (with camera, Mic) Diagnostic Device (optional) Printer 2 mbps per Desktop Mid Level Health Practitioner (MLHP) Nurse/Paramedic Details Details

Monitoring Framework Team Constitution Roles A Review committee of JS-NHM, JS-eHealth and JS-Medical Education To review the performance of the tele- consultation through this programme To provide the necessary instructions to the Medical Colleges / Technical Teams / States Quarterly Review Review Committee Director (NHM) Head Director (eHealth)-member Director (CHI) - member Assisted by Senior Consultant MoHFW To monitor the overall functions of the programme Coordinate with States Review of dashboard with KPIs National Monitoring Team Mission Director (NHM) Head State nominated Nodal officer Nominated HUB In-charge Project Monitoring Office (PMO) Operations Manager MIS expert To manage the overall operations of the project in State Creation of MIS for State, based on the Key Performance Indicators (KPI) State Monitoring Team Chief Medical Officer (CMO) Head Nominated District Level Nodal Officer MIS data entry operator Implementation and operations of Telemedicine solution Updating progress in the Dashboard Submission of reports to the State / New Delhi District Monitoring Team 12

Future Expansion National Medical College Network for Tele-Education MoHFW has created e-Classrooms in 50 Medical Colleges of country including AIIMS-Delhi, PGIMER-Chandigarh, SGPGI-Lucknow, JIPMER etc. for providing Tele-Education and Continued Medical Education(CMEs) services The network Is operational on high bandwidth National Knowledge Network (NKN) The NMCN network is created with the vision to provide collaborative ecosystem for Students for lecture sharing, e-Content generation , Storage and retrieval of E-Classroom Setup e-Content and a portal for students/filed level functionaries The NMCN network will vertically integrate with HWCs for Tele-Education services Field Level functionaries (ANM/ASHA) plays a vital role in delivery of services to this population Since these functionaries works in direct contact with major population, the continues skill upgradation is utmost important Continued Medical Education (CME) of Field level functionaries can help in Live surgery management of new diseases, quick action to contain any outbreaks and educate people on preventive actions

Future Expansion NMCN network is strengthened as Content Generation platform for medical education system M-eDX platform In line with popular eDX platform of Open Learning, a MeDX platform will be Live Lectures Online Medical Education Self Paced Learning Certification courses Training Modules Information dissemination platform Live surgery Animated Videos developed specifically for Medical Education over ONLINE mode with integration of National Digital Medical Library(NDML) Institutes like AIIMSs , PGIs will be designated as Centre of Excellence(CoE) assigning responsibility of eContent generation and approval for Online Medical Education courses Customized Online Certification Courses will be made available for ANMs/ASHAs/Anganwadi workers etc. in local language Services like Continued Medical Education (CMEs), Massive Online Open Content (MooCs) etc. would made open for Field Level health workers on this platform Doctors at District Hospitals/CHC/PHCs would be covered for enhancing their skilled and for Continued Medical Education (CME) Special short term courses would be designed for emergency diseases like ZIKA/NIPAH/EBOLA etc.

Future Expansion NMCN Scheme M-eDX Live Lectures Online Medical Education Certification courses Training Modules Information dissemination platform Live surgery Animated Videos 50 MEDICAL COLLEGES (to be expanded) Services Services Services Specialty Tele-Consultation Tele-Radiology Tele-CMEs PAN INDIA COVERAGE Government Healthcare Institutions Govt. Health & Wellness Centres State Medical Colleges DH/CHC/ PHC Aspirational Districts Doctors/AN Ms/ASHA/ Paramedics AYUSH

EXPECTED OUTCOMES a) Improved accessibility to quality health care b) Improved outreach of the specialist services to the rural part c) Reduction in the service delivery time d) Creation and transmission of Electronic Health Record (EHR) e) Timely access to the right clinician resulting in cost reduction f) Creation of database for disease patterns g) Promoting healthy lifestyle and behaviour h) Reduced burden on Secondary and Tertiary Healthcare System 16

THANK YOU 17

Tentative earmarking of HUBs to be finalized in consultation with States Operational HWCs Total Nodes to be attached Call Centre location States Covered Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow 254 1558 Uttar Pradesh (UP) IMS-BHU 0 1500 VSS Medical College, Sambalpur 158 1148 Odisha 10 34 Chandigarh Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh 117 1033 Punjab Indira Gandhi Medical College, Shimla 2 137 Himachal Pradesh Post Graduate Institute (PGI), Rohtak 27 408 Haryana Government Medical College, Jammu 72 380 J&K Andhra Medical College and King George Hospital, Visakhapatnam 365 1050 Andhra Pradesh Gandhi Medical College, Secunderabad 138 590 Telangana BACK BACK

Tentative earmarking of HUBs to be finalized in consultation with States Total Nodes to be attached Call Centre location Operational HWCs States Covered Madras Medical College, Chennai 930 1915 Tamil Nadu AIIMS, Patna 136 534 Bihar Patliputra Medical College, Dhanbad 47 776 Jharkhand 20 1814 Maharashtra 9 5 Goa King Edward Memorial (KEM), Mumbai 1 27 22 24 Daman n Diu Dadra n Nagar haveli B.J. Medical College, Asarwa, Ahmedabad 181 1645 Gujarat Government Medical College, Haldwani 44 426 Uttarakhand Sawai Man Singh Medical College, Jaipur 255 679 Rajasthan BACK BACK

Tentative earmarking of HUBs to be finalized in consultation with States Total Nodes to be attached Call Centre location Operational HWCs States Covered All India Institute of Medical Science (AIIMS), Raipur 719 800 Chhattisgarh Netaji Subhash Chandra Bose Medical College, Jabalpur 62 690 Madhya Pradesh 5 42 Meghalaya 2 39 Sikkim North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong 1 32 Mizoram 3 132 Arunachal Pradesh Guwahati Medical College, Guwahati 113 878 Assam Regional Institute of Medical Sciences (RIMS), Imphal 29 103 Manipur BACK BACK

Tentative earmarking of HUBs to be finalized in consultation with States Operational HWCs Total Nodes to be attached Call Centre location States Covered Agartala Government Medical College, Agartala 31 46 Tripura Christian Institute of Nursing Science & Research, Dimapur 5 63 Nagaland Trivandrum Medical College, Thiruvananthapuram 177 671 Kerala Karnataka Institute of Medical Sciences, Hubli 560 1142 Karnataka Andaman & Nicobar (UT) 2 34 JIPMER - Pudducherry 0 3 Lakshadweep (UT) 1 21 Puducherry (UT) BACK BACK

Minimum requirement @Spoke Remarks S. No. Item Description Estimated Cost /HWC 1 Telemedicine Diagnostic Kit To be provisioned as per choice of State 2 Desktop with headphone , microphone and HD web Camera 60,000 New equipment to be provisioned under PIP in case these equipment are not available at HWCs. 3 Printer 5,000 Should be met from the HWC budget including the untied funds. 4 Miscellaneous 5,000 5 Last mile connectivity To be provisioned in PIP as per actuals (Min. 2Mbps) 22 BACK BACK

Minimum requirement @5 seater HUB for 100 Spokes S. No . Item Description Qty Estimated unit cost Remarks 1. Desktop with headphone , microphone and HD web Camera 6 60,000 New equipment to be provisioned under PIP in case equipment are not available at HUB To be provisioned in PIP as per actuals. If the number of HWCs increases the number of MBBS doctors may be increased proportionately 2. MBBS Doctor 5 As per NHM guidelines 3. Specialist Doctors (On Daily remuneration basis) 4. Last mile connectivity 3 As per NHM guidelines To start with, a Specialist in General Medicine will be able to coordinate the HUB initially till other specialists are co-opted. - To be provisioned in PIP as per actuals (Min 2 mbps) 23 BACK BACK

E-Sanjeevani Application & Training S. No. Item Description Estimated Cost To be provided by MoHFW to all States/UTs 1 Development and Hosting of e-Sanjeevani Application 2 To be provisioned in PIP as per requirement of State/UT Servers for Database, Backup, Application, Load balancers etc. Training Cost States to include the cost associated with Training of staff in the PIP proposals as per actuals (NHM guidelines) A Handholding training to be organized in State Capital for all stakeholders CDAC-Mohali would prepare the e-Training modules in application for continuous learning of staff at HWCs 24 BACK BACK