As the MoHFW, GoI has notified the guidelines for the practice of Telemedicine in India you may use the simple steps enumerated below as guidance for running successful Teleconsultations using video conferencing.
Video Conference (VC) is a tool that allows users in different locations to communicate using technology and hold face to face to meetings. Broadly speaking video conferencing is of two types, a point-to-point VC which allows communication between two individuals and
multipoint VC which allows multiple people to see and converse together. Video Conferencing is almost an integral component of any Teleconsultation and thus it requires much effort and preparation. Here are the general principles, with a focus on multipoint conferencing:-
- At the hospital, a separate room should be set aside for the equipment, as it takes up a certain amount of space, and this also makes it available to more users. The setting should be “uncluttered”, that is, with walls and curtains in soft and solid colors. Strong patterns in the background or the participants’ clothing may be a distracting factor. It is wise to speak calmly and at an even rate. Sudden movement can create a disturbance and interference in the picture.
- For patients, single rooms are desirable so that they can talk to the doctor alone, or together with local health care staff. The optimal frequency for VC should be assessed. To ensure continuity, the same doctor should be responsible for contact with the satellites over a continuous period (for example, one month).
- Make sure the appointment is at a time which is comfortable and convenient for all participants. This becomes a bigger challenge when there are going to be participants from across the globe.
- A dress code is similarly required including combing your hair (shoes maybe optional!). When one is sitting at home, one conveniently forgets that they are very visible to other participants (So forget about doing VC from your bedroom!)
- Older systems allowed a separate camera which could be mounted at a particular place where they could ensure only what was required to be revealed of their home and office would be in the frame. This is not possible any longer as current laptops and even desktops have a camera at the top of the screen which does not move to face the speaker and thus positioning and zooming becomes a problem. Mobile based VC is simpler and is better done placed on a stand, but it is not without challenges.
- It is important to have a round of introductions – the system will allow for the name to be displayed while speaking.
- Microphone and ear plugs are better than speakers for sound quality, but do not obviate the need for a soundproof closed room, The main convenience is in stopping an echo effect caused by 2-3 second delay of audio reaching across and coming back through the listeners’ device as a fresh audio note. Any participant, who does not have head mikes, should remain muted at any time he/she is not speaking. Feedback (the loud crescendo type tinny sound when the mike faces the speaker) is another problem best avoided thus.
- Speaking out of turn is another frequent cause for confusion. Hence the conference organiser needs to have a moderator. Most systems allow a form of digital hand raising, but even better is that comments or questions be entered into the accompanying chat box.
- Hybrid meetings are wherein there is a physical presence in a room but some of the members are connected online. If this room has multiple speakers a table top multi directional mike would be preferred
- Similarly, for the hybrid meeting, more sophisticated cameras with turning to face the speaker would be important.
- The final speed and clarity depends on a calculated average bandwidth wherein some persons may lose the voice or video. During an ongoing conversation, it is even recommended that users switch off their video input to allow for better clarity all around.
- When making a presentation or on-screen discussions, it is important to remember that only one screen is normally allowed for sharing with others. – the choice could be the entire desktop of just a particular opened presentation or document – even a running EHR screen.
- Special problems, mostly of noise as well as no sound, emanate when switching from external mike to internal sounds of the system (e.g. when one wants to run a onscreen explanatory video) during a conference call. Solving these, tests the skills of even professional broadcasters.
- A possibility of remote control of the screen being viewed may be allowed for annotations. However again not more than one remote entity should do that.
Now we discuss some recommendations for VC as part of health support. We assume that the target is a possible teleconsultation and the same is being done through a telemedicine app.
- While the caller (a patient or preferably the local care provider) may use a mobile or desktop, for the clinician a desktop will be better as he should be comfortable and not moving around.
- Patient related data – history, investigation reports etc should be available through Store and Forward (S&F) for viewing in the same screen or sometimes a parallel side screen. The same depends on the system being used
- An ambient light source, preferably daylight from a window, should be behind the camera even if a desktop mounted camera. i.e., the speaker faces the light. Many systems allow for a light to be switched on when the video is active, but such lighting is rarely adequate, and if so may cause a glare or redeye of the speaker.
- Providing an appointment roster is important, e.g., Dr A shall be ready and awaiting calls from 1600 to 1700 hours.
- A background screen or display board behind the caller and more importantly, the clinician should reveal the identification and location of the consulting parties.
- The display screens should allow all the desired components with large enough fonts to avoid discomfort and specially squinting – which one must understand will be seen immediately on the other end. to allow and sometime for larger effect on two screens.
- Special telemedicine apps include all the above in an all to all inclusive system. They also support creation of ePrescriptions which are made by the clinicians but can be printed remotely with prescriber credentials, digital signatures, etc.
- Even though many now do all work through a mobile phone, the small screen is a however a hindrance, hence tablet computers, e.g., an iPad, should be considered a minimum.
- Most important is to try and ensure eye to eye contact with the patient (you just need to keep viewing your own video box to see if that is what it appears) as that shows empathy and concern.
Author, Entrepreneur and Surgeon. Dr. Gogia is a member of the Telemedicine Workgroup at IMIA. Dr. Gogia is also the President at SATHI & the Founder Member of IAHSI. His specialties include, Medical Informatics, Telemedicine, Managing Social Organizations, Plastic Surgery, Biomedical Engineeering
This is an excerpt from the book Fundamentals of Telemedicine and Telehealth, 2019
Republished on DHIndia Blog with permission of the Author.