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Bangladesh Journal of Bioethics 2015; 6(3):30-36 
 

 

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Original Article:  

 

Ethical aspects of Dhaka University Tele-medicine System  

 
Ahmed Raihan Abir 1, Shamima Parvin Lasker 2 

1. Department of Biomedical Physics & Technology,University of Dhaka, Bangladesh  

Email: raihan.abir@bmpt.du.ac.bd 

2. Professor & Head, Department of Anatomy, MH Samorita Medical College, Dhaka 

 

Abstract: To provide basic health care services in rural areas is one of the major challenges for 

developing countries like Bangladesh because of lack of infrastructures and unavailability of 

qualified medical doctors in the villages. Telemedicine viewed as a new way of offering health 

care services that has the potential to overcome this problem. Author is a member of extended 

group at Dhaka University (DU) which has been developing telemedicine equipment and data 

acquisition software to promote telemedicine practice in Bangladesh. PC based ECG equipment, 

Digital stethoscope, Digital microscope, Digital X-ray view box and some other essential medical 

equipment was developed for telemedicine services. The data acquisition software establishes an 

easy and appropriate patients to doctor interaction through a trained operator in a remote center 

that involve management and arrangement of consultation of a chosen and agreeing doctor by a 

patient. Upon establishing audio-visual connection between patient and doctor relevant 

physiological data from different diagnostic instruments will be uploaded securely in a dedicated 

web server which can be viewed real time using unique patient/doctor ID and password. Recently 

the Telemedicine group of DU and a local NGO named SAMAMA with support from Service 

innovation fund (SIF) of Prime Minister Office (PMO) of Bangladesh took the initiative to 

establish eight rural telemedicine centers and one expert center for the field trial of telemedicine 

in Bangladesh. The aim of this paper is to examine the ethical challenges of such health care system 

and our effort to overcome those problem before starting the field trial.  

Keywords: Telemedicine, bioethics  

Introduction: Almost 70% of total population live in rural areas of Bangladesh. There are only 

3.6 doctors for 10,000 people. For this reason many people tend to take religious medication from 

various religious institutions or consult village doctors who has little or no formal training for 

curative purpose 1. The WHO has identified the necessity for further medical resources in the 

developing countries and has suggested telemedicine as a promising solution 2.  Telemedicine can 

be defined as a practice of medicine over a distance, in which interventions, diagnostic and 

treatment assessments and recommendations are based on data, documents and other information 

transmitted through telecommunication systems. Bangladesh Government has recently established 

internet links with video capability to almost all the rural health complexes (called Upazilla Health 



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Complex), together with PC and necessary accessories. Recently thousands of rural community 

clinics have also been provided with laptop and internet connections. Therefore it is an appropriate 

field for the incorporation of telemedicine. In Bangladesh, several groups are working in 

Telemedicine. However most of these depend on video conferencing only having no diagnostic 

equipment at the rural end. Although some of these are using some diagnostic equipment from 

abroad, but the cost are prohibitively high. Besides, most of foreign equipment are not designed to 

work in the hot and humid climate under an uninterrupted electricity supply. Keeping these 

problem in view, the Department of Biomedical Physics and Technology (BMPT) at Dhaka 

University started developing a telemedicine system based on a PC with some integrated 

diagnostic equipments using information such as documents, laboratory results, ECGs, heart 

sound, digital photograph, real-time ultrasonography or video, video recordings and physiological 

data such as blood pressure, hemoglobin saturation, heart rate and spirometry can be transferred 

from rural center by secure web based application3-8. Hardware developed for telemedicine 

purpose has been tested, compared with existing technology and had been certified by an expert 

board formed by the Directorate General of Health Services to implement health programs and 

services for the ministry of health of Bangladesh.  

 

Figure 1: Basic Concept of Telemedicine System 

Telemedicine is rapidly becoming popular in many countries in the world. It has several 

advantages such as being cost effective and ability to provide better access to health care in remote 

areas in many parts of the world including developed countries. Like Telemedicine, as with 

anything new, there is often resistance. Gainsayers have been quick to cite possible ethical and 

regulatory complications associated with telemedicine. One of the major challenges is that of 

patients’ rights and confidentiality in the use of Telemedicine. There are still no standard 

guidelines and procedures in the practice of telemedicine which make both patient and physician 

uncertainity about the standard of practice and how to maintain confidentiality. Medical liabilities 

of such system are also very crucial. In cases where damages occur a clear identification of the 

medical liabilities involved has to be ensured 9. There are several guidelines for Telemedicine has 



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been found to overcome such ethical challenges mostly developed by the USA, UK, India and 

Australia which focus, to different extends, on clinical, operational or technical aspects of various 

types of telemedicine and tend to be specific or a sub-specialty with the medical field. Only three 

countries and one association have published ethical guidelines. After the publication of clinical 

guideline developed by the General Assembly of the World Medical Association in 1999 and 

Finland in 1997 and internet eHealth Code of Ethics was drafted in 2000 to ensure that the people 

can use the internet to manage health with knowledge of the risks and benefits. The World Medical 

Association (WMA) started four principles of telemedicine practice in ethical guideline 10. The 

aim of this paper is to examine the ethical challenges of such health care system in Bangladesh 

and how to uphold the ethical principles.  

 

 

Figure 2: BMPT DU proposed Telemedicine web application 

 

Procedure of Telemedicine in Bangladesh: DU developed Telemedicine offers a direct 

consultation between patient and a registered doctor, by creating a ‘virtual consultation’ 

environment through communication links as provided by existing technology. Since the invention 

of telephone, telemedicine started through telephonic conversation between a patient and a doctor 

at a distance. However, one can easily understand its limitations, so telemedicine did not go a long 

way in the past. In the present age, computers with their astonishing capacity and power with fast 

internet links can facilitate almost real time video & audio communication and other data transfer 

from electro-medical diagnostic equipment, creating an environment which is very close to direct 

consultation by a doctor. In general, doctor-patient relationship has been characterized by the 

clinician’s duties relating to confidentiality, risk disclosure and patients right to privacy and 

autonomy. In the present form of our Telemedicine system, a patient comes to a rural center 

manned by one or more trained technician and equipped with internet connected computers and 

appropriate diagnostic instruments. This rural center is connected to an expert center situated at 



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another place, possibly in a city or a district town, through internet. The expert center is manned 

by qualified doctors. The patient consults the doctor through internet communication and the 

doctor tries to acquire as much diagnostic information as possible during the session including a 

direct video conversation. The doctor then gives a prescription to the patient giving advice on 

medication, diet, physical movement or exercise, and may ask for carrying out some other 

specialized investigation and to come back with the report at a later session for update. A few 

doctors taking turns in one expert center can serve many remote rural centers, and distance is of 

no problem. Generally speaking, the medico-legal position of doctors involved in our telemedicine 

consultation is similar to that when telephone, fax, email or letter is used instead. All amount to 

the delivery of advice from remoteness and the standard of care and skill will apply. The patient –

physician relationship will be based on a personal encounter and sufficient knowledge of the 

patient’s personal history. It will be based on mutual trust and respect and will be assisted primarily 

by expert technician deployed in the rural centers.  

Historically, doctor-patient connection has been characterized by the clinical right to 

confidentiality and sovereignty. With the introduction of electronic mediation and the possibility- 

for extended facilities, the physician’s duties also increased. In our system, obligations, 

appropriately, are placed on both the rural and expert center. The service will be provided in a 

private setting with digital line. The consumer will be educated about the nature and purpose of 

the system, equipment and any potential breaches of confidentiality inherent in the technologies 

installed and will be question regarding the level of satisfactory action.  

Data confidentiality and security: DU developed Telemedicine web application has the 

capability to produce digital patient file, digital physician’s consultation, digital prescription and 

patient registration card. These will facilitate and improve the treating of sensitive medical data as 

well as the promises for using medical resources in an unusual degree and can thereby considerably 

contribute to the well-being of the patient. A research conducted by Kenyon reveals that security 

is not merely a technological challenge, but represents potentially significant human factor barrier 
11, 12. By improving the quality of health care, our system has no intention to degrade patients’ 

rights, in particular their self-determination. But as it will be a field trial certain evaluation of 

patient data is required to ensure better service and to gain better understanding about certain 

disease and demography. Therefore, the technician will let patient know about the future research 

possibilities with the data and will give a consent form. Each patient will have the right to share 

their medical data for research purposes. If any person doesn’t want to share his/her data it will be 

remain secured and will then only be accessed by the patient and physician involved. Our system 

follows the legal basic conditions for medical data processing and data security i.e. the discretion, 

the integrity, the accessibility of the data at any time and the verifiability of the data processing 

will be guaranteed as well. Web server containing all the medical information will be secured 

efficiently against any dangers resulting from open networks, particularly the Internet. Electronic 

patient’s files can only be opened by the treating physician and the medical assistants up to 

necessary magnitude, safeguarding the likelihood of an emergency access. Any access beyond will 



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require the approval of the patient. The medical secrecy will be ensured. The digital prescription 

with a documentation of the patient's medication will require the consent of the patient and will 

protect the rights of the physicians. In particular, physician's prescribing behavior can only be seen 

by the physician and won’t be available for a third party. Furthermore it will protect the 

pharmacists' right to hide their revenue from other pharmacies. Patient registration cards will 

require the consent of the patient. The right of the patient to keep his information secret will be 

ensured with access options to the information stored on the registration card.  

Responsibilities of Doctor and Rural Technician: To understand responsibilities of Doctor and 

rural technician let us first review how a direct consultation between physician and patient works 

with the help of rural technician in our Telemedicine system. A patient comes to a doctor, and the 

doctor gets information in various ways- a) Listening to physical complains from the patient 

directly through mobile phone either by audio or video call. b) Visual observation of the overall 

look of the patient. c) Special focused look at certain organs like eye, tongue, or skin, etc. d) 

Touching and pressing different points of the body of the patient to feel for any abnormality. d) 

Using different diagnostic devices to probe further into the body that which is not apparent 

externally. Some of these are used by the doctor on the patient directly (as a stethoscope), and for 

some s/he asks for data and reports of diagnostic tests carried out by others, to be produced during 

a later visit by the patient. e) Sometimes an assistant takes some prior information on the patient 

like height, weight, temperature, blood pressure, etc., and hands over the records to the doctor. 

Based on all information received, the doctor makes an assessment of the medical problem and 

may prescribe medicines, diets and give necessary advice.  

A physician whose consultation is sought through the use of telemedicine will store a detailed 

record of the advice s/he conveys as well as the medical data s/he received was conveyed. Both 

the physician and technician will ensure that the patient or family members caring for the patient 

are able to use telecommunication system and necessary instruments accordingly. They both will 

also ensure that the patient has understood the advice and treatment recommendations given and 

that the continuity of care is assured. There will be an emergency transportation service available 

and will be used when direct consultation between physician and patient is required.  

Implications of telemedicine in Bangladesh: Rural people are often deprived of proper medical 

treatment in Bangladesh as it is difficult to retain qualified doctors there. Telemedicine offers a 

solution but most of the current telemedicine systems in use in Bangladesh are based on 

videoconferencing only which may lead to incorrect diagnosis and wrong treatment. PC based 

diagnostic equipment, if added, could allow a doctor to assess and diagnose a patient better. Such 

equipment based telemedicine systems are available from foreign manufacturers, but the cost is 

very high. Since such PC based diagnostic equipment will be needed at each of the hundreds or 

thousands of rural health centers eventually, the final bill will be prohibitively high. Furthermore, 

if something goes wrong in any equipment, it will be very difficult to fix, if not impossible, to get 

it repaired locally that may interrupt the service to the people.  



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DU telemedicine project will essentially bring the services of qualified medical experts to the 

doorsteps of the common people throughout the country, even in the remote rural areas. Although 

a telemedicine cannot match a face to face consultation, it is much better than no consultation at 

all. Rural poor, particularly the marginalized people, women and the physically disabled are 

deprived of the consultation of a qualified doctor for most of their ailments, as it is difficult to go 

to a hospital or a clinic in the town, physically and financially too. Telemedicine can at least give 

them an opportunity of consulting a qualified doctor at a reasonably low cost at a center very close 

to their place of residence. Even in remote areas of industrially developed countries telemedicine 

has rooms to play. The use of indigenously developed diagnostic equipment and software for 

telemedicine has opened up the possibility of spreading this service out to a much larger 

population. Conceptually the whole of Bangladesh can be brought under a network with affordable 

costs. Since the equipment and the software are locally developed, local maintenance and repair, 

and that at low cost, is ensured, in turn ensuring sustained service.  

Conclusion: DU telemedicine system can lead to a big change with respect to improved healthcare 

within a few years for people living in rural areas through providing consultation of qualified 

doctors, and particularly, through providing vital diagnostic information using the diagnostic 

equipment that go with it. Indeed there are several ethical challenges of such system but is possible 

to overcome. Once this technology and the model of delivery are successful in Bangladesh, it may 

be possible to export the concept as well as hardware and software to other countries of the Third 

World, bringing a big positive change globally.  

 

References:  

1. Bhuiya A. 2009. Health for the rural masses:Insight from Chakaria - Monograph No. 8. 

ICDDR,B Cahpter 8.  

2. WHO Committee A. 2005. World Health Assembly eHealth Resolution (WHA 58/28). A58. 

:4–6.  

3. Rabbani K S, Amin Abdullah-Al, Bodiuzzaman A K M, Khan Ahamad Imtiaz, Abir Ahmed 

Raihan & Tarafder Zihad. An indigenously developed affordable and sustainable telemedicine 

system. Appropriate Healthcare Technologies for Low Resource Settings - AHT2012, 2014 

London, UK.  

4. Rabbani K S, Amin Abdullah-Al, Bodiuzzaman A K M, Khan Ahamad Imtiaz, Abir Ahmed  

5. Abir Ahmed Raihan & Rabbani K S. Indigenous development of a Computerised 12 lead 

diagnostic ECG Equipment. International Conference on Physics of Today, 2012a BUET, 

Dhaka. Bangladesh Physical Society.  

6. Abir Ahmed Raihan & Rabbani K S. Low cost computerised Stethoscope for 

Phonocardiography and real time Telemedicine. International Conference on Physics of 

Today, 2012b BUET, Dhaka. Bangladesh Physical Society.  



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7. Rabbani K S, Abir Ahmed Raihan & Bodiuzzaman A K M. 2011a. Design and Development 

of a Low Cost Personal Computer based ECG Monitor. Bangladesh Journal of Medical 

Physics, 4. 149. http://dx.doi.org/10.3329/bjmp.v4i1.14701.  

8. Rabbani K S, Al-Amin Abdullah, Abir Ahmed Raihan, Bodiuzzaman A K M, Khan Ahamad 

Imtiaz & Tarafdar M Zihad. 2011b. A Rural Health Monitor with Telemedicine. Biomedical 

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10. WMA. 2007. WMA Statement on the Ethics of Telemedicine [Online]. 58th WMA General 

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ournal of Telemedicine & Telecare, 2 Suppl 1. 68-71.  

 

Conflict of Interest: No 

Authors' Contributions: 1st author conceptualize and written the article whereas 2nd author 

scrutinized and meticulously contribute in correction of manuscript.  


