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Virtual Clinic: A Telemedicine Proposal for Remote Areas of Pakistan

Conference Paper · December 2013

DOI: 10.1109/WICT.2013.7113107

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 Virtual Clinic: A Telemedicine Proposal for Remote Areas of Pakistan
1 2 1
Atta-ur-Rahman Muhamamd Hammad Salam Shahid Jamil
1
Barani Institute of Information Technology, PMAS-AA University, Rawalpindi, Pakistan
2
The University of Lahore, Islamabad Campus, Blue Area, Islamabad, Pakistan
[email protected] [email protected] [email protected]

Abstract — In this paper, a proposal for telemedicine thirdly the concept of telemedicine and fourth the cost
approach in the rural areas of Pakistan is presented where effective telecommunication network nationwide.
healthcare facilities are not sufficient due to non availability In 1998, Carson [3] described the role of telemedicine
of doctors and medical staff. On the other hand 80% of the in the management of diabetes and chronic. It may include
female students join medical colleges and out of which only the evaluation of decision support systems, methodology
10% to 15% join medical field as profession. Our proposal is and framework by using system modeling as a key
to connect these rural areas with these non practicing lady approach for designing system infrastructure.
doctors through any communication media whether it is Armstrong et al. [4] presented an approach for
internet, GSM, WiMAX, Satellite etc. For this sake virtual
telemedicine technology. They have proposed a
clinics will be established in the remote sites, patients will
visit these clinics a nursing staff would be available to take
telemedicine project in which connection was set up
all necessary information that will be sent by a smart phone between the two departments of a remote and urban
to a registered doctor through a central system. Doctor in hospital. Videoconferencing, tele-radiology and tele-
return would prescribe and prescription will be sent back by presence were the key features of the link. Connection was
smart phone to virtual clinic via same central system. A based upon ISDN (Integrated Services Digital Network)
prototype of the proposal is established and survey results and satellite link. Within one year nearly 120 tele-
are presented for viability of the proposal. consultations took place between the hospitals. Results
indicated that tele-consultation had enhanced patient care.
Keywords – Virtual Clinic, Telemedicine, Decision Support Estimated cost saving was about sixty five thousand.
Systems, ICT Initially telemedicine was considered as an
unaffordable and unreliable technology. Excessive use of
I. INTRODUCTION information and communication technologies had made
telemedicine as a feasible, reliable and useful technology.
Pakistan is a densely populated country where the In 2007, Sood et al. [5] proposed that telemedicine can be
healthcare facilities are not available especially for those defined in different ways by researchers and technology
living in remote areas. From the report of Survey of users. In order to improve the knowledge about
Pakistan [1], major population belongs to rural areas. telemedicine, an analysis about the definitions of
Medical doctors prefer to work in urban areas due to living telemedicine can play an important role. Modern
facilities and other fringe benefits. Even there are some telemedicine is a branch of e-health that transfers
areas where hospitals are available but medical staff is far healthcare services from one location to another by using
from sufficient. This leads to a terrible situation. communication technology.
Telecommunication in Pakistan has playing a vital role In 2007, Yuechun et al. [6] proposed a wireless
in connecting people at very cheaper cost. This is due to a telemedicine system named as WISTA offering low cost
number of telecom operators working simultaneously and and easy to deploy systematic framework. It will assist
cellular network has been spread all over the country. patients during unfavorable conditions. Multimedia
According to [2], Pakistan was the world’s third fastest consultation occurs between multiple disasters sites to the
growing telecommunications market in 2008. Pakistan's control center of the disaster. Proposed system supports
telecommunication infrastructure is improving real time consultation offering quick treatment procedures.
dramatically with foreign and domestic investments into It uses a hierarchical architecture for implementation. For
fixed-line and mobile networks; fiber systems are being thick disaster areas, a layered structure is functional to
constructed throughout the country to aid in network support information distribution from large number of
growth. patients. Moreover, the performance of the system is
Telemedicine is a concept that focuses on any medical computed using OPNET simulation.
action concerning a factor of distance. In which the In 2004, Memon et al. [7] has proposed a telemedicine
interaction between doctors and clinic involve system that support both store and forward and real time
telecommunication technique. Telemedicine projects in consultation methods for quick and cost effective response.
developing countries provide a chance for people living in Relevant patient information has been sent using ISDN
rural areas to achieve better healthcare services. and satellite links. The system approaches towards the
On the other hand, there a resource consisting of non mobile doctor in all decisions. The system has various
practicing lady doctors; as in Pakistan majority of female advantages like reduces the cost and time, increases
students join the medical field during their studies but only efficiency and decreases rush in hospitals.
a fraction of these students joins it as profession. So the Malik, in 2007 presents an approach for information
proposal of virtual clinic takes into account four things for and communication in telemedicine. It highlights the
the solution of above cited problem, firstly the deficiency projects established by Pakistan and United State (Pak-US)
in healthcare services in rural areas of Pakistan, second the collaboration, SUPARCO a satellite based telemedicine
non practicing lady doctors as resource to be utilized, centers and establishing global telemedicine network by

978-1-4799-3230-6/13/$31.00 © 2013 46
connecting all medical college hospitals with district Moreover, the central system is responsible for registration
hospitals. of doctor and clinics and to send the patient’s information
In 2011, Karim, S. et al. [9] proposed a virtual to appropriate doctor based upon his/her ranking. The
medicine approach that is composed of a clinical decision ranking would be calculated by response time, area of
support system (CDSS) deployed at rural area, in order to expertise and seriousness of doctor to the system. The
provide medical facilities in an active way at reduced cost. doctor will be paid a reasonable amount for each
This CDSS diagnosis the patient and suggest prescription prescription he/she has made. Similarly, the patient may be
as well. The cases where it is unable to prescribe, it sends charged a nominal amount for prescription and pharmacy.
email to the doctor and store response in its database for
future use. In this research paper, complete setup of virtual III. COMPONENTS OF PROPOSED SYSTEM
telemedicine approach has been discussed. In this section, detail of each component of proposed
In this paper, a unique idea for healthcare provision in system is presented. The interconnections of these
rural areas of Pakistan is proposed, by utilizing the concept components are shown in fig-3. These components can be
of telemedicine, virtual clinic and unutilized medical named and categorized as follows.
personals. A. Virtual Clinic Side
Rest of the paper is organized as follows: Section 2 B. Doctors Side
presents the basic model of the virtual clinic, components
C. Central System
of the proposed system are given in Section 3, Section 4 is
based on implementation of the proposed scheme and o Registration Module
screen shots are presented while section 5 concludes the o Query Handler
paper. o Database Server
o File Archiving Module
II. PROPOSED SYSTEM MODEL o Decision Support System (DSS)
Conceptual diagram of proposed system model is given
in fig-1. The proposal consists of three sites, namely, the A. Virtual Clinic
patient side or virtual clinic, doctor side and the central This part is comprised of a clinic situated in the
system. Patients will visit the virtual clinics that are located remote site with at least one medical staff, preferably
in the remote areas. A nursing staff at each virtual clinic a Lady Health Visitor (LHW) or a Mid-wife or a male
will diagnose the patient by taking the vitals and other nurse. The clinic is equipped with a computer or a
necessary information. This information is comprised of smart-phone preferably (having GPRS facility) and
text, image and audio/video contents. All this information common tools for inspection of a patient like
will be gathered on an android/iPhone based tablet or Thermo-meter etc. The nursing staff would be able to
smart phone and sent to central system via GPRS. Text collect all the necessary information from patient.
may be entered in predefined fields, images, and audio B. Doctor Side
video may be taken from built-in camera and microphone Doctor side is comprised of a smart-phone app that is
in smart phone. Upon receiving this information in central owned by a non-practicing lady doctor. Doctor is
system, the information will be sent to registered doctor to already registered with the system. She would be able
his/her smart phone. Doctors in return would prescribe to get the patient detail as an alert from the provided
according to the information provided and prescription will app and to prescribe the patient in response to those
be sent back to central system. Central system will send
details.
the information back to virtual clinic. This concept is
discussed in details in subsequent sections. C. Central System
This is the most important component of the proposed
system. This system is a web-based system with
following sub-components.
a. Registration Module
This module is responsible for registration of
virtual clinics as well as the doctors to the
system, after collecting the required
information. So the clinics as well as doctors
get registered online through this central
system.
b. Web service/Query Handler
This module is responsible for data receiving
and transmitting among the doctors and the
clinics. When a request approaches from
clinic, this module parses the information
and categorizes it according to the contents
like text, image, audio or video. Text
contents are stored in predefined database
Figure 1. Conceptual diagram of proposed system table in the database server while images,
audio and video are stored in the file
archiving module. Technically this

2013 Third World Congress on Information and Communication Technologies (WICT) 47

 component is a “web service”. The benefit A. Android Based Smart App
of using a web service is that it can bridge Smart phones like Android based smart phones and tablets
the database and the client side. No matter, have gained a lot attention for the customer due to their
whether client is an android phone, an compact size and computation power. According to a
iPhone or even a website. recent survey a big percentage of software market is
c. Database Server shifted on these technologies and even laptops are being
A database server which contains a database dwindled during next decade. A smart phone, by one way
management system (DBMS) running on it, or other is similar to a computer. In our proposal, smart
is responsible for storing the information in phones are used during the prototyping due to the cost
the predefined tables and answer the queries effectiveness and built-in multimedia features like
whenever needed. camcorder etc. Android based implementation of the
d. File Archiving clinical and doctor side is given in fig-2a to fig-2j.
This module is used to store the attachments
provided by the virtual clinic in terms of
images, audio and videos. These contents are
not saved in database instead they are stored
separately while their references are stored
in the database. This is done for database
efficiency.
e. Decision Support System
A decision support system is integrated in
the proposed system that is able to provide
the following features and by using this, Figure 2a. Login Screen Figure 2b. Adding a new patient
doctors will be facilitated by a set of
recommendations before prescribing a
patient. In our proposal decision support
system will be added later.
• Suggesting appropriate medicine
for a specific disease
• Contra-indication from drug to drug
• Makes use of previous decisions
made by doctors to make new
suggestions

Figure 2c. Basic information Figure 2d. Obtaining symptoms

Figure 3. Data flow diagram

Figure 2e. Obtaining medical Figure 2f. Obtaining picture and voice if
history necessary
IV. IMPLEMENTATION OF PROPOSED SYSTEM
The proposed system has been implemented as a
prototype. This is consisted of the following software
modules.
A. Android/iPhone based smart Apps
a. Clinic side app
b. Doctor side app
B. Central System Web Portal
a. Database Server
b. Decision Support System
c. Web-service for query handling

Figure 2g. Extra information Figure 2h. Doctor side

48 2013 Third World Congress on Information and Communication Technologies (WICT)

Figure 2i. Received history Figure 2j. Prescribing the patient

In fig-2a, login screen for virtual clinic is shown. After

successfully login by provided user name, the virtual
clinic attendant will add new patient this is shown in fig- Figure 3e. New doctor Figure 3f. Doctor’s login form
2b. In fig-2c basic registration information of the patient registration form
is obtained. Special symptoms like fever, pain etc. is
obtained in fig-2d. Brief medical history is obtained in
terms of text and pictures in fig-2e. Screen in fig-2f
facilitate the clinic attendant to obtain the picture and
record voice of the patient if necessary. This is important
if there is some skin infection or rash to be shown to the
doctor and some voice related problems may be recorded,
so that doctor can easily diagnose the patient on the other
side. Additional health information like blood pressure
and diabetes can be taken in screen shot given in fig-2g.

Figure 3g. Patient viewing form Figure 3h. List of patients

Figure 3a. Login form Figure 3b. Virtual Clinic main

menu screen

Figure 3i. Patient’s detail Figure 3j. Patient prescription

form

Fig-2h shows the doctor side where patient information is

received all the information sent from the clinic side is
visible in fig-2i and finally the diagnostic screen is shown
in fig-2j, where doctor after prescribing the patient can
Figure 3c. Patient data collection Figure 3d. Voice recoding send the information back.
form

2013 Third World Congress on Information and Communication Technologies (WICT) 49

 B. iPhone Based Smart App VI. CONCLUSIONS
In Pakistan iPhone, iPod and iPad are also becoming This paper presents a novel idea of virtual clinic which
very popular and also software industry is focusing on is a telemedicine approach to facilitate rural areas of
project development in this side. For sake of diversity, in Pakistan where healthcare facilities are far from
this proposal, same replica of Android app is developed availability. Through this system the non practicing
for iPhone. Following figures comprehend this app. In fig- female doctors can be connected to the virtual clinics
3a, login screen for virtual clinic attendant is provided. through the information and communication technology.
After successfully logged in (by prior given username and In this way the patient would be benefited by a cheaper
password), fig-3b will appear. This figure shows the main diagnosis while at the same time the doctor would also get
menu of the clinic side. From this menu one can see a nominal amount for each prescription. Basic level
existing patients, today’s patients and also add a new prototype is developed which is comprised of doctor and
patient. In case of existing patient previous details will be clinic side smart phone apps and a web server. In future,
popped out. In fig-3c, required fields are filled by decision support system will also be incorporated and
obtaining patient information. This also includes a picture British National Formulary (BNF) will be added for drug
and or an audio recording which is shown in fig-3d. to drug and disease to disease contra-indication etc. Upon
In fig-3e, new doctor registration form is given which completion this proposal can great help the nation in terms
will appear only once. Upon successful sign up, doctor of cheaper solution to rural areas healthcare problems.
can login through fig-3f. In fig-3g, patient control panel is
given, from this form doctor can see incoming requests. REFERENCES
For viewing the incoming requests fig-3h will be popped [1] http://www.surveyofpakistan.gov.pk/index.php
up. This list will show the incoming request in the order [2] Joseph Wilson,"Telecom Regulatory and Policy Environment in
that most recent request will be at top. Upon clicking the Pakistan: Results and Analysis of the 2008 TRE Survey". 22nd
patient name in the list, patient detail form will be open January 2009.
which is shown in fig-3i and from fig-3j, doctor can [3] Carson, E. R., “Clinical decision support, systems methodology,
and telemedicine: their role in the management of chronic
prescribe the patient. disease.”, IEEE Transactions on Information Technology in
Biomedicine, Vol. 2, Issue: 2 , pp. 80-88, 1998.
V. VIABILITY SURVEY
[4] Armstrong, I. J. and W. S. Haston., “Medical decision support for
For viability of the proposal, some surveys are remote general practitioners using telemedicine.”, Journal of
conducted. In these surveys the villagers were informed telemed telecare, vol. 3(1), 27-34, 1997.
about the whole idea and then their views are gathered [5] Sood, S., V. Mbarika, S. Jugoo, R. Dookhy, C. R. Doarn, N.
Prakash and R. C. Merrell, “What Is Telemedicine? A Collection
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two villages were chosen and the survey reports are given Underpinnings. Telemedicine and e-Health.”, 13(5): 573-590,
in the table-1 given below. These surveys depict that a October 2007, doi:10.1089/tmj.2006.0073.
majority of the rural population is agreed on having [6] Yuechun , C. and A. Ganz., “WISTA: a wireless telemedicine
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Table 1. VILLAGE SURVEY REPORT National Conference on Emerging Technologies, pp. 106-111,
Village Name Population Agreed Disagreed Neither 2004.
(approx.)
[8] Malik, A. Z., “Telemedicine Country Report-Pakistan.” 9th
Mirpur 30000 81% 10% 9%
International Conference on E-Health Networking, Application
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[9] Karim, S., “Clinical Decision Support System Based Virtual
Another survey was conducted in which views of Telemedicine.” Intelligent Human-Machine Systems and
different types of doctors were taken. These survey results Cybernetics (IHMSC), vol. 1, pp16-21, 2011.
are shown in table-2. It can be seen from the survey report
that practicing young doctors and non practicing female
doctors are more inclined to the current telemedicine
proposal compared to senior practicing doctor. This
reason is quite obvious, as it is stated earlier, why a senior
practicing doctor wouldn’t bother to advise on each
notification on his/her smart-phone.

Table 2. DOCTOR SURVEY REPORT

Type Number of Agreed Disagreed Neither
doctors
Practicing 100 90% 4% 6%
Young Doctors
Practicing 100 70% 25% 5%
Senior Doctors
Non Practicing 200 95% 3% 2%

50 2013 Third World Congress on Information and Communication Technologies (WICT)

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