Telemedicine

 

By

Professor. Dr. Tapati Basu

And

Ms. Sudipa Ganguly

Associate Professor, Indian Institute of Social Welfare Business Management

And

Research Scholar of  Professor. Dr. Tapati Basu

 

This research paper was published in the SRM Private University Chennai on National Seminar in 25 February 2009.

 

Telemedicine may be defined as ‘the use of electronic information to communicate technologies to provide and support healthcare when distance separates the participants’¹.

 

The World Health Organization (WHO) defines Telemedicine 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 the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities."

Infrastructure requirement

 

Telemedicine systems consist of customized medical software integrated with computer

hardware, along with medical diagnostic instruments connected to the commercial VSAT

(Very Small Aperture Terminal) , ISDN or telephone lines at each location. Generally, the medical record/history of the patient is sent to the Specialist Doctors, who study and provide diagnosis and treatment during video-conference with the patient's end. These systems essentially use Internet technologies for transferring data and communicating between centers.

 

Relevance in the  Indian scenario

 

In a country like India some of the major hurdles in delivering proper healthcare  could be stated as

• Hospital infrastructure constraints

• Large population to serve, most residing in rural or semi-urban areas
• Non-availability of adequate experts –75% of qualified consultants practice in urban centers, 23% in semi-urban sectors and only 2% serve  in rural centers².
• Low-doctor patient ratio- about 5.97 physicians and 7.9 nurses per 10,000 population against a global norm of 22.5 per 10,000 population².
• Lack of both infrastructure facility and knowledge updating facility for medical practitioners in rural areas
• Poverty and illiteracy amongst the masses.

 

 

Some of the most visible advantages of telemedicine from the Patients perspective could be –

 

• Improved access to quality care.
• Access to specialized health care services to underserved rural, semi-urban and remote regions.
• Access to medical experts’ services to a large population
• Reduced clinical travel and unnecessary patient transfers-cost effective care
• Faster knowledge transfer

 

Potential benefits for practitioners would be

• Linkages with doctors and centers of excellence-education benefits, appropriate referrals and reduced professional isolation
• Doctors can retain their local patients
• Access to comprehensive patient’s data –offline and online
• Quick and timely follow up of patients after treatment
• Training and retraining at affordable costs
• Cater to patients from a wide and varied geographical region or territory

 

Other benefits to government and institutions would be

• Creating a wider care base –thus increasing viability of investments
• Low capital investment to create a facility
• Increased utilization of hospital resources
• Maintaining continuous relationship with old patients
• New models of care –nurse and technician led clinics
• Making health care more affordable and timely

 

Telemedicine projects in India

 

In India telemedicine programs actively supported by ⁶ :

• Dept. of Information Technology

• Indian Space Research Organization

• NEC Telemedicine program for North-Eastern states

• Apollo Hospitals

• Asia Heart Foundation

• State governments

 

The DIT has undertaken  as a facilitator an initiative to implement telemedicine projects in the states of West Bengal, Tripura, Kerala, TamilNadu, Himachal Pradesh, Punjab⁷.

In Himachal Pradesh, the referral centers were created in IGMC, Shimla and PGIMER, Chandigarh. The nodal centers were started in zonal hospitals at Mandi and Dharamshala, Civic hospitals in Pooh,Jhanjeli,Tissa,Banjar,Nerwa,Karsog,Rohru ,at district hospitals in Recong Peo,Regional hospitals at Kullu,Hamirpur,Chamba,Nahan,Keylong and at the community centre at Shillai, Sangra, Bharmaur and Rampur. These centers use ISDN connectivity .

In Tamil Nadu ,with the referral centre at Royapetah hospital , the telemedicine centers were started at the governement hospitals at  Thiruvanamalai, Kancheepuram, Thiruvallur, Krishnagiri,Ooty and Rameswaram. These centers also used ISDN connectivity.

 

A telemedicine  facility for Cancer treatment and follow-up has been setup in    RCC, Adyar , Chennai ,with nodal centers in Chennai, Ghandhigram,Nellore,Bhimavaram,Coimbatore and in Kanyakumari district.

 

A nodal centre at Andaman has also been set up . The connectivity is through ISDN and VSAT.

 

In Kerala the referral centre has been set up in RCC , Thiruvanthapuram ,with nodal centers in Kannur,Kochi,Pallakkad,Kozhencherry and Kollam. The centers use VSAT connectivity.

 

In Tripura-  Two referral centers in Agartala –one at  the Govinda Ballav Pant Hospital and the second at  Indira Gandhi  Memorial Hospital with nodal centers at the sub-divisional hospitals in Amarpur,Kanchanpur,Chailengta,Gandachera and at Kathalia have been set up using 512 kbps leased line.

 

 

 

 In WestBengal ,with the referral centre at the  School of  Tropical Medicine ,Kolkataand nodal centers at Habra State General Hospital and MJN Hospital, Coochbehar ,the telemedicine project was completed using 512 kbps leased line connectivity on the WBSWAN.

In another project , with the referral centers at NRS Medical College & Hospital, Kolkata and the Burdwan Medical College & Hospital, Burdwan ,the nodal centers were started in  Purulia District Hospital, Purulia, Suri District Hospital, Birbhum, Baharampur District Hospital, Murshidabad , Midnapur Medical College & Hospital, Midnapur using a 512 kbps leased line on the WBSWAN.

In a third project , with referral centers at  Calcutta Medical College & Hospital, Kolkata,  North Bengal Medical College & Hospital,  Siliguri and  Chittaranjan National Cancer Institute, Kolkata, the nodal centres were started in Darjeeling District Hospital, Darjeeling , Raigunj District Hospital, Uttar Dinajpur, Tamluk District Hospital, Midnapur (East), Arambag Sub. Div. Hospital, Hoogly  ,using an ISDN link for Arambagh and 512 kbps leased line on WBSWAN for the rest.

 

According to statistics from DIT ,Telemedicine usage in West Bengal , between November 2002 and November 2007 using the above has been ⁷:

 

Leprosy	20
Pediatric	75
Orthopedic	106
Neurological	35
Cardiovascular Medicine	49
Psychiatric	15
ENT	45
OBG	09
Urosurgery	10
Hematology, Dermatology, General Medicine, etc	3546

 

The case

 

 

The Telemedicine project is a "NonProfitable" project sponsored by Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS) Kolkata , Narayana Hrudayalaya (NH) Bangalore, Hewlett Packard, Indian Space Research Organisation (ISRO) and the state governments of the seven North Eastern states of India. The Rabindranath Institute at Kolkata and Narayana Hrudayalaya at Bangalore are the main Telemedicine linking hub for the seven states. The specialists at both the institutions offer their services for this project entirely free of charge. The project tried to identify a 100-bedded hospital in each of these seven states and the hospitals were to be selected based on distance from the state capital and the lack of a coronary care unit.

 

 

The telemedicine project at RTIICS was started in 2001 as a joint venture with the governments of West Bengal and Tripura. The first three centers along with the adjoining Coronary Care units (CCU’s) were set up in Siliguri , Bankura and Udaipur in Tripura with the first Coronary Care Unit inaugurated in Siliguri District Hospital, Siliguri, West Bengal on 24^th June, 2001 and then at  Bankura Sammilani Medical College and Hospital, Bankura, West Bengal on 21^st July, 2001.The  Udaipur center in Tripura was started on 22^nd August,2001. The fourth center in  Tinsukia Assam, started on 1^st August 2002.  RTIICS was the referral hospital for all these centers.

This project was unique since all previous telemedicine projects in India were based on Out-patient basis, where patients came for consultation through Internet technology and then left , as in other out-patient departments. The Management of RTIICS, led by the world renowned cardiac surgeon, Dr Devi Shetty, felt that this kind of treatment of patients was inadequate in cases of cardiology where, if someone came after a heart attack, by merely- confirming the same through a teleconsultation would be inadequate to save the life and so he started a 6 bedded fully equipped CCU in each of the four centers for patients who required immediate admission ,thrombolysis or some other super speciality treatment in addition with the tele-consultation .

 

The respective governments in their local hospitals provided these spaces for the Critical Coronary Care units and the manpower was initially provided by the RTIICS. This manpower comprised trained staff - doctors, nurses and CCU technicians who could take the special ECG, perform cath-lab procedures, use defibrillators and administer life saving drugs in the critical hour of a heart attack .They were also trained in IT technology to manage and run the services independently . After the initial handholding, in the Siliguri center, the nurses were provided by the government hospitals, in Udaipur the doctors and the nurses were provided by the hospital and the technicians were provided by RTIICS. In Bankura all the three types of staff were provided by RTIICS and the life –saving drug Streptokinase was also provided free of cost to the patients from that center. In the other two centers the respective governments provided the drug to its patients.

 

The services provided by these centers are round the clock every day of the year. There is intense use of technology in all these centers. The services provided may be listed as follows :

• Tele-consulation – using Video-conferencing facilities –for emergency, non-emergency and follow-up cases.

E- ECG(Electronic-  ) – where a complete ECG is conducted on a patient using a special ECG machine developed by S.N Informatics in Bangalore. This device has six leads and the ECG can be taken for 10 –20 seconds or as desired. Once a ECG is taken , the center connects to the referral hospital through a special software and a telephone line using Internet technology to transfer the data . Once the ECG appears on the desktop of the hospital , it is printed and a specialist is consulted .A pre-designed format is available with all necessary information that the consulting doctor fills up and it is then sent back through the Internet to the local hospital. This report is printed locally  and the residing local doctor along with the report, simultaneously gets the opinion and advise of his senior colleague and is able to treat the patient accordingly. This entire process takes upto a maximum of 15-20 minutes –when in any normal case the complete activity- requires atleast 6 hours Further , no clinic works round the clock for this kind of tests in the regions where these facilities have been made available.

• At the referral hospital’s monitor there is an alert every time a fresh ECG arrives almost like an email. A specialist looks at the same and fills in an online format with his opinion and observation. Once completed, it is sent back to the local hospital in the same way. The local center can then take a printout, which shows the graph as well as the specialists’ opinion and observation on the right. The entire process takes anywhere between 15 and 20 minutes at the most.
• When a patient arrives with a cardiac arrest or failure, the doctor on call can use the video-conference facility with the referral hospital and a specialist who assesses the condition of the patient and decides on the treatment which is then administered locally- like use of defibrillators , thrombolysing or performing cat-lab procedures. This facility is of tremendous help to patients and increases their chances of survival if they receive this medical attention within an hour of the heart attack, known as golden hour. It also provides the patient with a specialist who is far more experienced in handling such cases than the local doctor and also reduces the travel and cost of travel thereof for the patient.
• Other reports like radiology reports, CT Scans, USGs  are scanned locally and sent to the referral hospital. Very soon new machines are going to be installed where the reports will be created digitally and sent automatically to the referral hospital.
• A specialist from the referral center gives virtual rounds through video-conferencing to check the admitted patients on a regular basis. He can in one session monitor the condition of patients in all the centers. He conducts the same through a two-way videoconference with his admitted patients and doctors, monitors the necessary parameters and also suggests treatment, which is provided to the patient by the local doctor. Every bed has its own monitor and camera unit.
• At the Kolkata center, many patients come specifically to be treated and checked by Dr Devi Shetty, who is presently based in Bangalore. For that, they are provided with teleconsultation through  video-conference facility. The patients’, reports like-angiogram film, ECG report, previous observations by other doctors are sent in advance through internet and is ready at the Bangalore console of Dr Shetty. At the appointed time, Dr Shetty arrives at the studio, the patient , his kin and a resident doctor are ready at the Kolkata studio. The teleconsultation begins like any normal consultation in real-time -with Dr Shetty asking questions to the patient. He simultaneously reads the reports and plays the films on his monitor and advices. The local doctor provides necessary clarification to both Dr Shetty and the  patient. All this is done through a VSAT link provided free of cost by ISRO ,using Internet technology.
• The same methodology is practiced for all other teleconsultations with other specialists both from the local centers as well as from the referral centre.

 

 

 

Patient flow :

These center operate round the clock every day of the year.

Once a patient arrives  –he is checked locally  by a doctor and a tele- ECG is done on him. The recorded data is automatically sent to the referral hospital – RTIICS. This trans-telephonic-ECG is done using a special device and software developed by SN Informatics in Bangalore as mentioned above.

If the condition is found to be critical,  the patient is admitted to the CCU or else referred to teleconsulting through video-conferencing .

 

 

 

Patient arrives

E-ECG performed at local center

Report and advice sent from referral centre at RTIICS

Is patient critical?

Yes

No

Referred to OPD- Telemedicine unit

Admitted to CCU at the local telemedicine centre

Virtual round by specialist from RTIICS. Procedure / medication advised

Thrombolysis, cath-lab procedures, defibrillation etc performed by local doctors and staff. Disease management controlled by specialist at RTIICS during the period of hospitalization

Discharged

Transferred

Discharged on risk bond

Expired

 

 

In-patients department

For the admitted patients , who are necessarily  in  a critical condition ,every morning the specialist from the referral center does a virtual round on the patients through internet based video-conferencing. This specialist consultant from the referral center actually takes charge of the disease management of these patients and instructs doctors, technicians and staff to administer the treatment locally. In most cases, these doctors at the local hospitals are not as experienced or qualified as the doctor from the referral hospital. These centers are thus able to provide best quality treatment to their patients using lower level manpower , in backward ,underdeveloped and far flung areas because of Internet technology through a virtual experience very close to the real experience. In the process,  they  and are also  being able to bridge the distance gap and reduce the traveling agony of their critical patients by bringing the service closer home. It may also be noted that the cost of bridging the distance through this technology is quite minimal –at times the cost of a local phone-call only.

In most of these cases, critical patients require immediate life saving procedures –like defibrillation or thrombolysis , which the trained technicians provide locally after the doctor from the referral hospital instructs them.  .

In the Bankura centre, RTIICS provides the Streptokinase drug free of cost to its patients.

 

Teleconsultation and out-patient department

 

For the patients who do not require immediate hospitalization, they can avail of tele

-

consultation. In these cases all vital reports related to the patient are sent in advance to the referral hospital in a digital format (X-ray reports, Scan report ,Tele-ECG and others) either as an email or through net-meeting . At the appointed time the specialist sits in the studio of the referral hospital while the patient along with a local doctor sits in the studio of the local hospital and the consultation takes place. There are certain doctors interested in tele-medicine who take provide maximum consultations , however , the patient may also choose a doctor  ,who then gives an appointment .Incase of follow up of patients , the same process as OPD consultation is repeated. The other advantage of such a system is the reduction in waiting time of a patient. In most cases there is no waiting time unless there is another Video-Conference is going on , this is because the center has only one VC unit at the moment.

 

 

 

RTIICS provides both the tele-consultation and ECG services free of cost .

 

Apart from government collaboration , certain other centers were started with private partners as well. These were in Tinsukia-Assam, in Purulia, Jamshedpur and Chittaranjan. In southern India the centers are at Sargur, Hulkoti, Kundapur, Bidar, Chamranrajnagar, Pakisthan, Malaysia and Bangladesh and are connected to the Narayana Hrudalaya at Bangalore.

 

In West Bengal there are presently 13 centres with tele-ECG facilities.

 

Research Question

 

Given this background and the active use of Internet technology in the delivery of these services it would be necessary to analyze the following question:

 

 Has the use of Internet positively impacted disease management in the case of critical cardiac patients?

 

Methodology

 

 

The Case study method

 

The case study method has been applied to carry out a qualitative analysis by observation, interviews through focused and non-directive methods and data collection with an intention to study the impact of Internet on health, especially in critical cardiac health problems amongst population which are located in areas without proper medical facilities  (Kothari , 2006) .

 

The data were collected from three telemedicine units connected to Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), Kolkata, namely, Siliguri and  Bankura in West Bengal and Udaipur in Tripura. In all, seven telemedicine centers were connected to RTIICS. Of these four centers at Purulia, Jamshedpur and Chittaranjan and Tinsukia in Assam were being run through non-government collaboration. The centers at Siliguri, Bankura and Udaipur in Tripura were being run through government collaboration. The center at Purulia was not performing satisfactorily and was therefore closed down. The centre at  Jamshedpur, which was being run by a doctor was closed down when the new Brahmananda Narayan Hrudalaya was started and the center at Tinsukia was closed down when RTIICS started its own hospital there. Therefore, the study was conducted on the three active centers at Siliguri, Bankura and Udaipur.

 

Detailed interviews were conducted with the heads of these units and the head of the unit at RTIICS. Interview was conducted with a telemedicine consultant specialized in cardiology at RTIICS and deeply involved in this project. Live sessions of teleconsultation through videoconferencing were observed and four trans-telephonic ECG  reports were studied and the process observed.

 

 

Data collected

The data of patients admitted at the CCU of the telemedicine centers at Siliguri and Bankura were collected for a period of 90 months and at Udaipur for 89 months. The meaning and relevance of the variables are explained in Table (  )

Table( ) . Meaning and relevance of data variables for numerical analysis

 

Variable name	Meaning	Relevance
TOTP	Total number of critical patients admitted to the CCU at the telemedicine centre.	These critical patients have all undergone treatment through Internet technology. All these patients have had at least one tele-ECG and one video-consultation by a specialist from the referral hospital.
DIS	Number of critical patients discharged from the hospital.	These critical patients have undergone treatment through the tele-medicine project and have had their disease managed successfully. They are well enough to go home. This process indicates reduction in mortality4 or death and may be interpreted as the reduction in the  rate of death from cardiac diseases in the population. This variable also indicates reduction in morbidity5 – that is  - diseased condition or state or the incidence of cardiac diseases in the population.
TH	Number of critical patients who have undergone thrombolysis at the telemedicine centre. This is in most cases a life-saving procedure and helps to reduce mortality and morbidity immensely.	According to the medical dictionary3   a Thrombolytic agentis a drug that is able to dissolve a clot or thrombus and reopen an artery or vein. Thrombolytic agents may be used to treat a heart attack, stroke, deep vein thrombosis, which is a clot in a deep leg vein, pulmonary embolism, and occlusion of a peripheral artery or indwelling catheter. All thrombolytic agents are serine proteases that digest protein and convert plasminogen to plasmin, which breaks down the fibrinogen and fibrin and dissolves the clot. Currently available thrombolyic agents include reteplase (r-PA or Retavase), alteplase (t-PA or Activase), urokinase (Abbokinase), prourokinase, anisoylated purified streptokinase activator complex (APSAC), and streptokinase. They are also called clot-buster, clot-dissolving medication, fibrinolyic agent. These agents are administered into the patients system through cath-lab procedures, which has been referred to as thrombolysis.
TRANS	Number of patients transferred to general ward from CCU	This variable indicates critical patients, of the system whose condition improved and they could be shifted to a general ward. It also indicates reduction in mortality and morbidity.
REF	Number of patients referred to RTIICS (the referral hospital) after being stabilized from the critical state for further treatment in most cases surgery	These critical patients after stabilization are sent to RTIICS for further treatment, in most cases for surgery. This variable also indicates that the patient’s life at that critical hour could be saved and his/her condition improved to an ambulatory state. This factor also indicates reduction in mortality.
EXP	Number of critical patients expired, in spite of medical intervention at he center.	This variable indicates the number of patients who expired in spite of intervention by local doctors and specialists from the referral centre through telemedicine. These patients are in a very critical and damaged state and the disease may be complex. Hence it may not always be possible to save the life.
DORB	Number of patients discharged on risk bond, after being stabilized.	This variable indicates the number of patients who after being stabilized by the telemedicine centre may be removed by the family or kin to other available facilities for further treatment.

 

 

Numerical method

 

Varimax-rotated R-mode factor analysis or Principal  Component Analysis (PCA) was applied to achieve the above objectives (Usnoff and Guzman, 1984;

Yang

,

1999

; Hicks et al, 1999; Sikdar et al., 1993, 2001; Ballukraya and Ravi, 1999; S´anchez- Martos et al., 2001; Rao, 2001; Yip et al. , 2003; Hoon Kim et al., 2004; Kaplunovsky, 2005; Mrklas et al., 2006; Sikdar and Chakraborty 2008). In the present work, PCA has been applied using SPSS v.10 software.

 

The principal components are the eigenvectors of a variance-covariance matrix.  The methodology (Davis, 1973) involves three steps:

 

• standardization of the raw data in terms of a zero mean, a unit variance and the computation of the variance-covariance matrix;
•  computation of a set of   mutually orthogonal Principal Component axes (the elements in each axis referred to as ‘loading’) which are actually the eigenvectors of a variance-covariance matrix, where the corresponding eigenvalues denote the proportion of variability accounted for by the respective PCaxis; and
• computation of a set of PC-scores for each of the varimax-rotated factor PC-axis, corresponding to individual samples.

 

Factor 1 is related to the largest eigenvalue and explains the greatest amount of variance in the data set. Factor 2 (orthogonal to and unrelated to the first) explains the greatest of the remaining variance and so forth..

 

Varimax rotation via the Kaiser normalization procedure has been used to calculate the rotated factor matrix. The rotation makes the factors easier to interpret by maximizing

the differences between the variable (Lee et al.,2001; Invernizzi and de Oliveira, 2004). The rotation takes place in such a way that all the components of the factors are closer to +1, 0 or -1, representing the importance of each variable. A loading close to ±1 indicates a strong correlation between a variable and the factor, while a loading close to 0 indicates a weak correlation (Wayland et al., 2003). Variables, which exhibited a rotated loading >0.5 were considered significant. Each of the PC-axis or factors (with high loadings on one or more variables) may be representing an independent source of variation in the data matrix and these may give some clues to genetic processes (Harman, 1967).

 

The factor scores are related to the impact of Internet on health of the critical patients at the Telemedicine clinic described by each factor. Extreme negative numbers (< -1) indicate areas unaffected by the process and extreme positive numbers (> +1) indicate areas most affected. Near zero numbers is an indication of areas affected to an average degree (Dalton and Upchurch, 1978; Lawrence and Upchurch, 1982).

 

 

 

Results

 

 

Principal Component Analysis

 

Varimax rotated R-mode factor analysis or Principal Componenets Analysis (PCA) was carried out to investigate the impact of Internet on processes of disease management in the case of critical cardiac patients.

 

It is well known that, if there is early invention and when  treatment can be provided locally, without patient traveling to cardiologist centers, it saves on crucial time and cost  and can significantly reduce the morbidity and mortality of critical patients. In this context the research was done on the data for in-patients only, who were treated as emergency patients and admitted o the Telemedicine CCUs. The data of the outpatient department teleconsultation was also available but was not considered since the condition and health of the patients were assumed to be less critical.

 

 

The PCA was carried out using data collected from three centers- Siliguri, Bankura and Udaipur. The data was collected month-wise for the period July 2001 to December 2008 in the cases of Siliguri and Bankura  and for the period August 2001  to December 2008 in the case of Udaipur on 7  variables. Of these, data on 6 variables ,namely Thrombolyzed (TH), Discharged (DIS),Discharged on risk bond(DORB), Expired (EXP), Transferred to other wards (TRANS),Referred to RTIICS (REF) as detailed above ,were used.These 6 variables are the most important indicators of the impact on disease management in the case of critical cardiac patients through Internet.

 

These variables underwent PCA involving varimax rotation with Kaiser normalization .It should be noted that combining such a diverse mix of data may have stretched PCA to its extreme limit, but this may have revealed some exciting information on the impact of disease management through Internet. Loadings above 0.6 were only considered significant .

The first five factors were selected to represent the dominant impact on disease management without losing any significant  information.

Siliguri

 

The output of the PCA (Table…) reveal that the first five eigen values together account for over 93% of the total variability of the combined population /variable.

The first principal component (PC1) ,which accounts for more than 29% of the total variance has significant loading on REF (0.92), and DIS (0.78).Very  high loading on REF   indicates that  critical patients have stabilized and shifted to the referral centre at RTIICS for further treatment thus reducing morbidity and mortality .High loading on DIS indicates that critical patients have stabilized after intervention and are fit to be discharged.

The second principal component (PC2) , which accounts for 17.0% of the total variance has very high loading on DORB (0.95). This factor reflects that very critical patients are partially stabilized and are then being removed to other facilities available in the city for further treatment.

The third principal component (PC3), which accounts for 17.0 % of the total variance has very high loading on TRANS (0.98) . This factor indicates that patients have stabilized and are fit to be transferred to a general ward of the hospital.

 

The fourth principal component (PC4), which accounts for over 16.0% of the total variance has very high loading on TH (0.99) , This factor indicates that patients were stabilized after thrombolysis performed by local doctors in collaboration through Internet technology with doctors from the referral centre at RTIICS.

 

The fifth principal component (PC5) , which accounts for over 16% of the total variance has very high loading on EXP (0.97). This factor indicates that the critical patients have expired  inspite of intervention by the local doctors in collaboration with the doctors from the referral centre .

Table :   . Principal Component Analysis using 90 samples from Siliguri

 

Variables	Loading on PC axes
	PC1	PC2	PC3	PC4	PC5
TH	0.043	0.004	0.078	0.994a	0.054
DIS	0.778a	0.349	-0.034	0.044	0.190
DORB	0.118	0.952a	0.155	0.002	0.116
EXP	0.194	0.124	0.101	0.058	0.965a
TRANS	-0.008	0.143	0.980a	0.081	0.095
REF	0.922a	-0.063	0.021	0.022	0.087
% Eigenvalue	25.149	17.802	16.696	16.689	16.679
Cum %	25.149	42.951	59.647	76.337	93.015

^a Variables with significant loading
Bankura

The output of the PCA (Table…) reveal that the first five eigen values together account for over 93% of the total variability of the combined population /variable.

The first principal component (PC1) ,which accounts for more than 22% of the total variance has significant loading on DIS (0.84), and TH (0.77).High loading on DIS indicates that critical patients have stabilized after intervention and are fit to be discharged. High loading on TH indicates that patients were stabilized after thrombolysis performed by local doctors in collaboration through Internet technology with doctors from the referral centre at RTIICS.

The second principal component (PC2), which accounts for 17.8 % of the total variance has very high loading on EXP (0.96), This factor indicates that patients have stabilized and are fit to be transferred to a general ward of the hospital.

The third principal component (PC3) , which accounts for over 17% of the total variance  has very high loading on TRANS (0.97). This factor indicates that patients have stabilized and are fit to be transferred to a general ward of the hospital.

The fourth principal component (PC4) , which accounts for 16.5% of the total variance has very high loading on DORB (0.99).  This factor reflects that very critical patients are partially stabilized and are then being removed to other facilities available in the city for further treatment.

The fifth principal component (PC5) , which accounts for 16.78% of the total variance has very high loading on REF (0.99). This factor indicates, critical patients have stabilized and shifted to the referral centre at RTIICS for further treatment.

 

Table :   . Principal Component Analysis using 90 samples from Bankura

 

Variables	Loading on PC axes
	PC1	PC2	PC3	PC4	PC5
TH	0.768a	0.361	0.067	-0.119	-0.129
DIS	0.843	-0.090	-0.266	0.105	0.051
DORB	0.003	0.003	-0.002	0.991a	-0.045
EXP	0107	0.963a	-0.054	0.041	-0002
TRANS	-0.139	-0.052	0.970a	-0.0007	0.078
REF	-.003	0.963a	0.074	-0.046	0.990a
% Eigenvalue	22.215	17.819	17.069	16.854	16.782
Cum %	22.215	40.034	57.103	73.957	90.739

^a Variables with significant loading

 

 

 

 

 

 

 

 

 

 

 

 

Udaipur

 

The output of the PCA (Table…) reveal that the first five eigen values together account for over 92% of the total variability of the combined population /variable.

The first principal component (PC1) , which accounts for more than 21% of the total variance has significant loading on REF (0.94) and DIS (0.61) . Very high loading on REF indicates that critical patients have stabilized after intervention and shifted to the referral centre at RTIICS for further treatment. High loading on DIS indicates that critical patients have stabilized after intervention and are fit to be discharged.

 

The second principal component (PC2) , which accounts for 20.7 % of the total variance has very high loading on TH (0.95). This factor indicates that patients were stabilized after thrombolysis performed by local doctors in collaboration through Internet technology with doctors from the referral centre at RTIICS.

 

The third principal component (PC3) , which accounts for almost 17% of the total variance has very high loading on TRANS (0.99). This factor indicates that patients have stabilized and are fit to be transferred to a general ward of the hospital.

 

The fourth principal component (PC4) , which accounts for 16.8% of the total variance has very high loading on DORB (0.99).  This factor reflects that very critical patients are partially stabilized and are then being removed to other facilities available for further treatment.

The fifth principal component (PC5) , which accounts for 16.68% of the total variance has very high loading on EXP (0.99). This factor indicates,  that critical patients have expired inspite of intervention by local doctors and doctors from the referral centre through Internet technology.

Table :   . Principal Component Analysis using 89 samples from Udaipur

 

Variables	Loading on PC axes
	PC1	PC2	PC3	PC4	PC5
TH	0.086	0.949a	0.010	-0.006	0.077
DIS	0.614a	0.575	0.097	0.095	0.032
DORB	-0.025	0.021	-0.007	0.997a	0.002
EXP	-0.006	0.077	0.049	0.002	0.996a
TRANS	-0.038	0.035	0.995a	-0.007	0.048
REF	0.940a	0.061	-0.081	0.065	-0.019
% Eigenvalue	21.152	20.721	16.797	16.781	16.687
Cum %	21.152	41.874	58.671	75.452	92.139

^a Variables with significant loading

 

 

 

In a second analysis, Varimax rotated R-mode factor analysis or Principal Componenets Analysis (PCA) was carried out to investigate the impact of Internet on processes of disease management in the case of critical cardiac patients on the composite data from the three centres namely - Siliguri, Bankura and Udaipur.

 

The data was collected month-wise for the period July 2001 to December 2008 in the cases of Siliguri and Bankura  and for the period August 2001  to December 2008 in the case of Udaipur and collated into one database. The analysis was done on  6 variables ,which are Thrombolyzed (TH),Discharge (DIS),Discharge on risk bond(DORB),Expired (EXP),Transferred to other wards post recovery (TRANS),Referred to RTIICS (REF).

These 6 variables are the most important indicators of the impact on disease management in the case of critical cardiac patients through Internet.

 

These variables underwent PCA involving varimax rotation with Kaiser normalization . Loadings above 0.6 were only considered significant.

The first five factors were selected to represent the dominant impact on disease management without losing any significant information.

 

 

 

 

 

 

 

 

 

 

Table :   . Principal Component Analysis using 239 samples from Siliguri, Bankura and Udaipur

 

Variables	Loading on PC axes
	PC1	PC2	PC3	PC4	PC5
TH	0.173	0.053	-0.021	0.979a	-0.049
DIS	0.865a	0.122	0.245	0.223	0.129
DORB	0.126	0.166	0.077	0.049	0.973a
EXP	0.662a	0.592	0.051	0.050	0.089
TRANS	0.157	0.933a	0.094	0.050	0.165
REF	0.191	0.092	0.970a	-0.023	0.076
% Eigenvalue	21.569	21.243	16.997	16.950	16.775
Cum %	21.569	42.813	59.810	76.760	93.535

^a Variables with significant loading

The output of the PCA (Table…) reveal that the first five eigen values together account for over 93% of the total variability of the combined population /variable.

The first principal component (PC1) ,which accounts for  22% of the total variance has significant loading on DIS and EXP. High loadings DIS  indicates critical patients have been cured enough to be discharged and slightly less loading on expired indicates that certain critical patients have expired at the centre  . 

The second principal component (PC2), which accounts for 17.0% of the total variance has high loading on DORB and moderate loading on DIS and TOTP. This factor reflects that critical patients are stabilized and are then being removed to other facilities available in the city for further treatment.

The third principal component (PC3), which accounts for 17.0 % of the total variance has high loading on TRANS and moderate loading on TOTP,. This factor indicates that the patient has stabilized and is fit to be removed to a general ward.

The fourth principal component (PC4) , which accounts for 16% of the total variance has high loading on EXP . This factor indicates that the critical patient has expired .

The fifth principal component (PC5), which accounts for over 14.0% of the total variance has high loading on TH , This factor indicates that the patient was stabilized after successfully thrombolyzing through telemedicine.

 

The first two components of the factor analysis have been plotted as perpendicular axes representing all parameters (Fig ) . The x axis   represents the combined process of   discharge and expiry (factor1) and the y axis represents the process of transfer (factor 2).

 

Extreme negative numbers that is < –1 indicates areas unaffected by the process. Extreme positive numbers >+1 are most affected by the process. Near 0 numbers indicate areas affected to an average degree.

 

 

 

 

 

 

Figure :

 

Graph showing PCA Scores (PC1 versus PC2 ) from 239 samples .

 

 

 

 

 

 

 

 

 

 

 

Based on factor scores of PC1 and PC2 the graph has been classified into 15 zones

which are as follows :

 

 

Zone	Factor 1	Factor 2	Observation	Centre	Remarks
I	0 to +1	0 to +1	Moderately affected by both factors	Siliguri
II	0 to +1	0 to -1	Moderately affected by both factors	Bankura
III	0 to -1	0 to –1	Moderately affected by both factors	Udaipur
IV	0 to -1	0 to +1	Moderately affected by both factors	Bankura
V	> +1	0 to +1	Highly affected by factor 1 and moderately affected by factor 2	Siliguri
VI	>+1	0 to -1	Highly affected by factor 1 and moderately affected by factor 2	Bankura
VII	>+1	< -1	Highly affected by factor 1 and highly unaffected by factor 2	Bankura
VIII	0 to 1	<-1	Moderately affected by factor 1 and highly unaffected by factor 2	Bankura
Zone	Factor 1	Factor 2	Observation	Centre	Remarks
IX	0 to -1	<-1	Moderately affected by factor 1 and highly unaffected by factor 2	Udaipur
X	<-1	<-1	Highly unaffected by factor 1 and also highly unaffected by factor 2	Udaipur
XI	<-1	0 to -1	Highly unaffected by factor 1 and moderately affected by factor 2	Udaipur
XII	<-1	0 to +1	Highly unaffected by factor 1 and moderately affected by factor 2	Siliguri
XIII	<-1	> +1	Highly unaffected by factor1 and highly affected by factor 2	Siliguri
XIV	-1 to +1	> +1	Moderately affected by factor 1 and highly affected by factor 2	Siliguri
XV	>1	>1	Highly affected by factor1 and highly affected by factor 2	Siliguri

 

 

 

 

 

 

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