TELE-OPHTHALMOLOGY IN TRIPURA

1 TELE-OPHTHALMOLOGY IN TRIPURA AUGUST 2011 Researched and Documented By: OneWorld Foundation India

2 Contents Executive Summary... 3 Background... 4 Objective... 4 Working Design... 4 Methodology... 7 Key Stakeholders... 7 Lessons Learned... 7 APPENDIX A 11

3 EXECUTIVE SUMMARY In order to overcome the challenges of inadequate resources for ophthalmologic 1 care in the state the Department of Health and Family Welfare, Government of Tripura, in 2007, initiated the Tripura Vision Centre - a teleophthalmology project that utilises information and communication technologies (ICT) to facilitate quality eye care to people residing in rural locations. 2 This project is considered a success as it optimally employs the existing resources and adopts advances in telemedicine programmes in order to address overall eye care needs of the state s population, at an affordable cost. There are a total of 40 Vision Centres (VCs) in the state one for each block. All the VCs of the state are established in the premises of Community Information Centres (CICs) set up under National e-governance Plan (NeGP). The calculative move of establishing VCs adjacent to CICs served the purpose of leveraging existing infrastructure and Tripura State Wide Area Network (TSWAN) connectivity along with attracting locals who visit CICs for a host of citizen centric services provided. The VCs are connected to the Indira Gandhi Memorial (IGM) Hospital in the state capital Agartala from where the ophthalmologists tele-consult the patients. Ophthalmic assistants at the VC screen the patients and enter information in the database. The assistants also capture the images of the eye which are uploaded to the database along with the patient s history. With the help of TSWAN, relevant information is transferred to the referral centre, where the images are diagnosed and the modality of treatment is prescribed. The decentralisation of healthcare enabled through VC has led to increase in the number of women screened to 10 percent during 2007-2011. Total number of glass prescribed from the vision centres 43,433 and total number of refraction performed are 96,222. Total number of cataract patients identified till July 2011 are 5533 and total number of cataract surgery performed till July 2011 are 3480 under the project. The successful implementation of the tele-opthalmic project in Tripura is reflected in the number of patients being screened during the period April 2007- July 2011-1,28,200 out of which 56 percent are male and 44 percent are female. Though the project had initially faced challenges such as lack of suitable site for vision centre layout, shortage of modern infrastructure, unstable current supply and unavailability of ideal space for tower, it could mitigate those in short time through expertise and mutual cooperation from all the stakeholders. Observing the success and replicability of the Tripura tele-ophthalmologic project, the Planning Commission of India is contemplating to replicate the model in the 12 th Five Year Plan. 1 Ophthalmology is the branch of medicine which deals with the diseases and surgery of the visual pathways, including the eye, brain, and areas surrounding the eye, such as the lacrimal system and eyelids. 2 Telemedicine, 2011-08-02, http://telemed.esanjeevani.in/telemedicine/teleophthalmology.aspx

4 BACKGROUND Tripura has an acute shortage of modern ophthalmologic infrastructure and specialists. There is only one public sector hospital, the Indira Gandhi Medical (IGM) Hospital, in the capital of the state that serves the need for all secondary and tertiary care support. Seventy-five percent of the population that reside in the rural areas have to spend considerably on transportation and accommodation to avail the service. Apart from the IGM hospital there are only three secondary care centres and three primary care centres in the state. At present, a total of 17 ophthalmologists and 26 ophthalmic technicians are catering to the needs of 37 lakhs residents. By 2014, the numbers are estimated to reduce further as out of the 17 ophthalmologists, 10 will retire from the service, implying that only 8 or 9 ophthalmologists will be providing eye care to a projected population of 40 lakhs. This trend is bound to increase pressure on ophthalmologic infrastructure and expertise at the state healthcare mission. Moreover, geographical location of Tripura presents an inherent FIGURE 1 VISION CENTRE challenge of easily accessing services and expertise from the mainland India as it is physically distant because of Bangladesh. The government of Tripura has initiated measures to address these concerns by increasing the number of ophthalmologists to minimum one per 50,000 populations; however, it will require a considerable amount of time to achieve this target. Therefore, to offer a pragmatic solution, the state government decided to adopt information and communication technology (ICT) to extend the benefits of the advanced medical sciences to the entire population, including the remote and inaccessible parts of the state, through Tripura Vision Centre programme. OBJECTIVE The Tele-ophthalmology project implemented by the Ophthalmology Department, Department of Health and Family Welfare, Government of Tripura aims to combine advances in medical sciences and ICT to offer primary and preventive eye care services to the rural citizens of Tripura. WORKING DESIGN Project Infrastructure vity of network nnectivity. Hospital. upply to all g online rs. The tele-ophthalmology project required setting up of vision centres in all the blocks of the state in order to decentralise eye care to meet the requirements of the rural population of Tripura The project was implemented in three phases to cover all 40 Blocks of rural Tripura. The first phase was commenced in the month of April 2007 on a pilot basis in Melaghar. Based on the progress made the project was upscaled in September 2008 to include 10 additional blocks with a population of approximately 15 lakhs. The third phase, was completed in 2009 to cover the rest of 29 blocks of the state. acilities FIGURE 2 THE PROJECT INFRASTRUCTURE

5 The Vision Centres (VC) are established adjacent to Community Information Centres in order to leverage the existing Tripura State Wide Area Network (TSWAN) infrastructure at the CICs. These VCs are connected to the IGM hospital located in state capital Agartala. Opthalmic assistants are incharge of registering and screening the patient, and are also responsible for entering the patient s history in the database. Diagnosis in eye care is more focused on the images of the retina and the posterior of the eye. The VC captures the images of the eye which is uploaded to the database along with the patient s history. ICT is utilized to transfer the images of the diseased eye to the referral centre where the pictures are diagnosed and prescribed the modality of treatment. Required Equipments Network Architecture of the Project The equipment required for the technology-based treatment process is same as regular ophthalmology process. The medical equipments used include a slit lamp, direct ophthalmoscope, streak retinoscope, trial set with frame, +78D lens, digital camera, schiotz s tonometer, starilizer etc. In addition, the technological hardware required for the project is desktop computer with multimedia kit, including a web camera and a printer. Network architecture In order to facilitate video conferencing and data transfer between the VCs and the IGM hospital Mulitprotocol Label Switching (MPLS) wireless VPN (peer to peer) connectivity and State Wide Area Network (SWAN) connectivity are established. Wireless network is also deployed to operate with Near Line of sight (LoS) in most areas and non Line of Sight in some areas. FIGURE 3 NETWORK ARCHITECTURE For uninterrupted tele-consultation with patients from VCs across 40 locations a real time consultation facility is established in the IGM hospital with required web based video conferencing software and VCMS module for validation of doctors and sending out signed prescriptions.

6 Database of patients history The ophthalmologic assistant enters the patient s history to the centre s database along with the images of the eye that can be easily shuffled between the secondary and tertiary care hospital as and when required. The VC database server is located at the IGM Hospital in Agartala. Human resources Seventeen ophthalmologists from the IGM hospital are diagnosing and treating patients through tele-ophthalmology in 40 blocks of the state. Ophthalmic assistants are screening and examining the patients, filling up the data in the online module along with taking care of both clinical and non clinical infrastructure in the VCs. They conduct regular tele-consultation with the ophthalmologist at the base hospital. There are also Multi Purpose Workers (MPWs) who register FIGURE 4 PATIENT SCREENING the patients and counsel them in case they require attending the base hospital for further treatment. Arvind Eye Care Hospital, Madurai, Tamil Nadu; and Netra Niramay Niketan, Haldia, West Bengal give training of the ophthalmic assistants and MPWs on a regular basis. Monitoring Regular supervision and cross examination of the service delivery with assistance from the Management Information System (MIS) generated data along with hospital reports enable accurate measurement of the quality and effectiveness of the service offered. Diseases diagnosed Catract Pterygium Lid disease Blunt Trauma Corneal ulcer FB PCO Corneal Opacity Fungal Keratitis Viral Kertitis Anterior Retinal problem Chalazion Hazy cornea Entropion Uvetis BRVO ARMD Squint Ptosis High IOP Optic Atrophy Def. Vision Glaucoma Dacryocystitis Asthenopia Corneal Scar High Myopia High Hepermetropia High Astigmetism Physician Check Up

7 METHODOLOGY The Governance Knowledge Centre (GKC) research team identified the tele-ophthalmology project of Tripura as a best practice because this is a comprehensive model for providing primary and preventive eye care in a decentralised manner using the benefits of Information and communication technologies (ICT) integrated with the medical eye care solutions. The team used both primary and secondary research methods for the preparation of this best practice document. Conducting desk based secondary research, available through online material the team gathered important information on the background, operations and achievements of Tripura Vision centre. In order to validate the secondary research findings, the team adopted the interview method to carry out primary research. Responses were obtained from Dr Sukumar Deb, Deputy Superintendent- IGM Hospital, Department of Health and Family Welfare, Government of Tripura through telephonic interview on many important aspects of implementation of the programme. The insights obtained were utilised with the desk research to prepare this document. KEY STAKEHOLDERS The Department of Health and Family Welfare, Government of Tripura conceived the tele-ophthalmology project. It is responsible for allocation of doctors as well as its budget for successful operation of the project. The Department of Information Technology, Government of Tripura helps in promoting the project across the state. National Rural Health Mission shares the financial liability with the state government. IL & FS Education and Technology Services Ltd and Arvind Eye ecare System designed the project for the government of Tripura. They bring in required technology and clinical partners for the project. IL & FS also creates an administrative framework for VC management along with ensuring meeting of project deliverables. IL & FS and Arvind Eye ecare also build capacity for managing the project within the health system of the government. LESSONS LEARNED Leveraging ICT to offer advanced medical care Tele-medicine as a promising branch of advanced medical care was not much popular in Tripura prior to the conception of the Tripura Vision Centres. The project is an innovative attempt to deliver eye care services using sophisticated yet easily replicable technology to even the most marginalised person of the remotest part of the state. Articulate distribution of VCs around the state and each of its uninterrupted connectivity with the base hospital are enabling patients to obtain eye care service on a daily basis from 9 am to 4 pm. Appropriate utilisation of technology is mitigating the acute shortage of man power and infrastructure in the state. Convergence with CICs The CIC project of the government of India was implemented with the aim of bringing the multifarious benefits of ICT to the grassroots in the relatively remote and less developed regions of India. 3 Apart from providing basic services such as IT education, training, internet access and e-mail, CICs established under National e-governance Plan also provide citizen-centric services. The government of Tripura in an innovative approach decided to establish all the VCs adjacent to all the CICs. It helped VCs to use dual connectivity, one from CIC i.e. TSWAN and another is from private MPLS-VPN network provided by Tulip. This move of the 33 Chaudhri nadita and Shefali S Dash, Community Information Centres, 2011-08-03, http://www.csisigegov.org/casestudies/13_cics.pdf

8 government of Tripura helped in reducing the cost of civil infrastructure by the health department on connectivity. The location of the VCs adjacent to CICs has helped in outreaching the rural population as they often visit the CICs for other government-to-citizen (G2C) services. Year April'11-July'11 Year 2010-11 Female Male Total 9434 11241 20675 14404 19957 Year 2009-10 Decentralisation of eye care 34361 Prior to the establishment of vision centres the 6608 Year April'07 - March'09 8101 patients had to travel to the capital of the state 14709 Agartala for ophthalmic care. 75 percent of the FIGURE 5: TOTAL PATIENTS SCREENED population of the state who reside in rural areas had to spend a lot of money on travelling and accommodation. With the establishment of four vision centres in semi urban locations and 36 in rural areas of the state ophthalmic care became decentralised. The massive increase in the number of patients screened due to the decentralised service delivery is shown in the diagram: 25516 32959 58475 Integration of primary, secondary and tertiary care Eye Glass Prescribed 43433 Total Refraction Performed 96222 Majority of the patients visit VCs for treatments related to refractive errors. 4 The numbers of patients with cataract surgical requirements are lesser and are referred to secondary eye care service hospital only after video consultation from the VCs. Tele-ophthalmology helps in reducing the unnecessary patient transfer to secondary care facilities. Thus, the project enhances the capacity of the existing ophthalmological services in Tripura by structurally integrating the primary, secondary and tertiary care. FIGURE 6: EYE GLASS PRESCRIBED AT THE VISION CENTRE 4 The inability of the eye to accurately focus the rays of light coming from distance on the retina is called refractive error. Glass and contact lens often correct refractive error.

9 Number of refral patients treated & cured till July 2011, 5478 Number of refral patients till July2011, 8340 Increase in women s participation In the initial stage of the project it was observed that percentage of women being screened in the government hospital was considerably low. With establishment of vision centres, eye care service was taken to the door step of the rural people leading to an increase in the number of women being screened in the centre. Prior to the implementation of the project 34 percent women and 66 percent men were FIGURE 7: NUMBER OF REFERAL PATIENTS TREATED AND CURED AS OF JULY 2011 Source: IGM Hospital screened in the government hospital. Now, with the improvement in accessibility, more women are encouraged to come out of homes for diagnosis and treatment, resulting in 10 percent increase in women s participation. Percentage of Men & Women Screened in Govt. Hospitals & Screening Camps b/w 2005 and 2009 Total Patientss Screened w.e.f April'07 to July'11 Total - 128220, Male Patients Screened - 72258, Female Patients Screened - 55962 Female 34% Male 66% Female 44% Male 56% Creation of trained manpower In order to ensure quality human resources, the government provided training to qualified medical technicians to familiarize them with necessary skills required in the field of ICT and advanced medical sciences to operate clinical and non clinical infrastructure in VCs. These capacity building exercises for the project were in collaboration with Arvind eye care hospital in Madurai, Tamil Nadu and Netra Niramay Niketan, Haldia, West Bengal.

10 Leveraging existing resources The project uses the already existing infrastructure of the state by establishing the VCs in CIC premises. The government did not have to procure any special equipment apart from the mandatory medical and IT equipments such as slit lamp, direct ophthalmoscope, streak retinoscope, digital camera, sterilizer, desktop computer, multimedia kit, web camera etc. The establishment cost of 40 centres including site preparation, equipment and manpower charger was Rs 3,24,25,686. Running and maintenance cost of the project per year is Rs 1,60,07,857 with an enhancement of 10 percent per year. Entire financial liability is borne by the NRHM and government of Tripura. In case of Tripura this is the best financially viable ophthalmic care service that helps the state government in reducing the acute pressure that was build up due to extreme shortage of ophthalmic care in the state. The project at present is offered to the poor patients of the state free of cost. Challenges and the way ahead The project had initially faced challenges such as lack of suitable site for vision centre layout, lack of modern infrastructure, unstable current supply and unavailability of ideal space for tower. However with diligent planning, efficient management and continuous dialogue among all the stakeholders the challenges were mitigated. The task of humanising and localising information communication technology as well as medical advancements to serve at the grassroots was one of the major challenges of the Tripura government. The success in dealing with this particular challenge makes the tele-ophthalmology project of Tripura Vision Centre a unique one. The scalability and replicability of this ongoing project has inspired the Planning Commission of India to replicate the model in the 12 th Five Year Plan of the country. Research was carried out by the OneWorld Foundation, Governance Knowledge Centre (GKC) team. Documentation was created by Research Associate, Ajupi Baruah For further information, please contact Mr. Naimur Rahman, Director, OWFI. REFERENCES Chaudhri Nadita and Shefali S Dash, Community Information Centres, 2011-08-02, http://www.csisigegov.org/casestudies/13_cics.pdf ehealth India 2009 Award for Government/Policy Initiative of the Year, 2011-08-02, http://www.eindia.net.in/2009/awards/pdf/tvc.pdf Tripura Vision Centre Project, 2011-08-02, http://www.eindia.net.in/2010/awards/details/ehealth_gvtpolicyinitiative-details.asp?pno=5 Telemedicine, 2011-08-02, http://telemed.esanjeevani.in/telemedicine/teleophthalmology.aspx

11 APPENDIX A Interview Questionnaire Background: 1. When was the Tripura Vision Centre project implemented? What was the motivation behind implementing the project? a. Can you describe the status of eye care services in Tripura prior to the implementation of the project? 2. What is the current geographic scope of the project? How many centres are there in every district? a. Vision Centres (VC) are established in Community Information Centres. Are there VCs in all CICs in the state? If no, what is the basis for selecting project location? 3. Are these centres in both urban and rural areas? Please provide statistics on existing VC in both urban and rural area 4. Why did the government choose to integrate VCs with CIC? Stakeholder: a. Are these CICs established under National e-governance Plan (NeGP)? If no, please elaborate on the structure of CICs in Tripura. 5. Government of Tripura s Department of Health and Department of Information Technology, together with IL & FS are key stakeholders of the project. Are there any other stakeholders? If yes, please list the stakeholders and explain their roles and responsibilities. Working design: 6. We understand that the Tripura Vision Centre model was designed in three phases. Can you explain these phases in detail? 7. How does the teleopthamology work? What kind of Information and Communication Technologies are utilised to treat/diagnose patient? a. What are the infrastructural requirements for setting up VC? b. Does teleopthamology require government to procure special equipment? If yes, what are they? 8. What kind of technological connectivity is used for exchanging data between VC and base hospitals? a. If real-time data exchange is not used, then what kind of data storage facilities is used at TVC? b. Are there any challenges in data transferring? 9. As per our research, the VCs are connected to IGM hospital based in Agartala. Are there any more base hospitals that are connected to VCs?

12 10. Can you explain the roles and responsibilities of Multipurpose Workers (MPWs) and Opthalmic Assistants (OA)? 11. What kind of training and capacity building measures are provided to VC staff to handle medical practices as well as to maintain clinical and non clinical infrastructure in VCs? 12. Our research indicates that the project enhances the capacity of prevalent eye care system of the state of Tripura by structurally integrating the primary, secondary and tertiary care. How does this project carry out the integration of primary, secondary and tertiary care? 13. We understand that the application of ICT tools utilised in the project not only takes eye care services to the rural areas but also enables measuring the quality and effectiveness of the service really offered. How is this process of measuring quality and effectiveness of service delivery carried out? Financial Aspect: 14. Would you consider this model to be cost effective, if yes, why? 15. Can you describe the financial model of the project? Is there a revenue generating mechanism? If yes, how does it work? 16. Can you provide us a breakdown of initial costs for: Site preparation, equipment, technology, manpower etc? Challenges: 17. Were there challenges in designing and implementing the project? If yes, what were they and how were those overcome? Impact and Achievements: 18. The project states that there has been an increase in the percentage of women patients over the years due to the initiatives taken by the project administration. What kinds of measures were taken to popularise the programme among the masses? a) What are the indicators to prove increase in women s participation? Provide data. b) Provide data on total number of patients screened so far, percentage of women, percentage of men. 19. Can you provide quantitative data indicating the achievements of the project? (For example, provide data supporting the project s contribution towards avoiding needless blindness). Scalability and replicability 20. Is there any plan to replicate the tele-medicine model to provide treatment for other diseases in Tripura? If yes, please provide details. 21. Has the project been replicated in any other state of India?