|TELEMEDICINE IN RUSSIA
Author: Svetlana M. Bye
Date: 15 August 2003
This memorandum was originally intended as part of the document "The NST and Russia". It was rewritten in connection with the NST's participation in the Norwegian-Russian telemedicine symposium held in Moscow in April 2003.
Information about what is happening in telemedicine in Russia should be interesting for everybody at the NST. For this reason, programme manager Liv Karen Johannessen suggested preparing a larger version in the form of a internal information memorandum.
The memorandum contains the essence of the existing information available about telemedicine in Russia, reference to official documents about telemedicine and links to relevant organizations and institutions. The links have been checked and updated, with the proviso that changes may have been made to home pages mentioned after the memo was completed. Brief comments on organizations and institutions are based on official references as well as personal knowledge and impressions.
The introduction of telemedicine in Russia
Way back on 24 January 1900, the Russian professor Aleksandr Popov organized radio communication for calling acute medical help. The main users of this communication were crews and passengers on several ships in the Baltic Sea.
In other respects, telemedicine in Russia developed at the same time as the space expeditions. From the voyage of the first sputnik passenger (the dog Laika) follow-up using a variety of telemetry equipment
was an important part of the expedition. It was the only way to monitor the state of health of cosmonauts in space. All aspects of space medicine actually involve telemedicine, focusing on ECG and other cardiac examinations transmitted and monitored at a distance.
This year, it is 100 years since the birth of Vassilij Parin (picture), the physiology professor who pioneered medical examinations in space. Parin took part in the development of many cardiac examination methods, for example seismocardiography, which was developed specially for cardiac examination in space,
and mathematical analysis of cardiac rhythm. Medical electronics and biotelemetry were also among his research areas. Biology and medicine in space are some of the most important research areas, and experience from these disciplines has been presented at several national and international conferences.
In the 1980s, greater clinical emphasis was placed on general "earthly" telemedicine. For example, a Russian-American group worked together on teleconsultations for people injured during the earthquake in Armenia in 1988. A telemedicine bridge linked Armenia with several medical centres in the USA. The Ministry of Health and the Institute for Space Medicine collaborated with NASA. More than 300 teleconsultations were conducted.
Moscow and the regions
At "earth level", telemedicine has developed in various regions both far from the centre and in Central Russia, primarily thanks to collaborative projects with other countries. The Far East has collaborative projects with Japan, north-west Russia with Norway, the Ukraine with the USA, etc. Another motivating factor is local wealth: oil, gas, diamonds, etc. Those who take part in collaborative projects see the potential for equipment purchases and payment for communication. Generally, oil-rich areas copy the systems of the experienced users in other regions (equipment, communication functionality) and buy the same products they have seen
, for example, in Arkhangelsk. Regions with advanced industrial and scientific sectors are also among the eager developers and users of telemedicine.
It is said that some 40 regions in Russia have experience in / use telemedicine.
Moscow plays a special role in this context. On the one hand, Moscow wants to reinforce its position as the hub for other regions and function as "the administrative centre" for telemedicine enquiries from outlying areas, and does so because there are large medical centres with leading-edge competence there.
One example is the project "Telemedicine: Moscow – regions in Russia". The project is headed by Valerij Stoljar at Russia's leading institute for cardiac surgery, and concerns teleconsultations for current and potential patients with cardiovascular diseases.
Consultations before admission improve efficiency by helping to reduce the number of hospital bed days at the institute, and the number of empty beds.
On the other hand, institutions in Moscow rely on experience in telemedicine and innovations from the regions; they summarize them and present them in the corridors of power.
Some limited-liability companies have been established, such as Diamorph http://www.diamorph.da.ru, and private firms, for example, TANA http://www.tana.ru/ENG/index.htm with its head office in Moscow, which sells equipment. "Packages" are offered, often with options which are not necessary for small and medium-sized hospitals.
Fibre-optic lines link 44 health institutions in Moscow. Here, both the Internet and broadband are used for telemedicine. Some of the large clinics hire out the roofs of their large buildings for the communication companies' satellite dishes, and in return they obtain ample "free" communication with the outside world via ISDN and IP. For example, you can view direct transmission of heart operations via three cameras http://oper.med.ru/sablin/
This clinic would like Norwegian doctors and medical students to look at these operations. Some of them are saved in a Net-based archive. From 3 to 4 June 2003, the Cardio Centre at Russia's Ministry of Health held the conference "Guidelines for reduction in incidence and mortality of the principal cardiovascular diseases". Cardiologists from several cities in Russia took part in the conference through videocommunication.
There are at least 10 centres in Moscow which organize teleconsultations at leading federal hospitals after enquiries from regions in Russia. One of them is highly experienced and arranges consultations for children in several regions in Russia. Here you can find their pages in English: http://www.telemednet.ru/Sen.htm
Consultations are provided free of charge by Russia's foremost specialists in a variety of paediatric diseases.
A document package signed on 14 May 2002 marked the start-up of the Telemedicine Agency (read: TANA group). The objective of the Telemedicine Agency is to function as a multiprofile provider of telemedical services on a scale comparable with Internet and mobile telephony service providers. This indicates that society and the authorities in Russia are ready for the introduction of telemedicine in the public health service.
A number of organizations have been established to coordinate a broader introduction of telemedicine in practice.
1997: "Telemedicine Fund", an initiative by the Ministry of Health, the Russian Academy of Medical Science and the Ministry of Science
2000: Telemedicine Association
2000: The Council for the Coordination of Telemedicine at the Ministry of Health and the Russian Academy of Medical Science
2001: Committee "Russia's telemedicine"
2002: Programme "Electronic Russia 2002-2010"
The Telemedicine Fund is headed by Oleg Orlov. Many documents are available in Russian at http://www.telemedicine.no:9101/index.html
Their "English home page" is unfortunately blank. They regularly post electronic news about telemedicine from all over the world.
The Telemedicine Association is headed by the cosmonaut Oleg Atjkov, professor of cardiology.
The programme "Electronic Russia" was posted on the Net for public discussion. The official hearing was available on the Internet.
The Ministry of Health has "telemedicine" as a permanent item on its official Internet pages, and has signed a number of documents relating to IT health. Of particular importance is the Directive No. 279 of 14.07.99. "Regarding principal guidelines for development of IT in Russia's public health service". The document describes what telecommunications, technologies and global corporate networks associated with health should be used for.
They are to be used for:
Systems for Consilia Medica
Training, further education, post-qualifying education, and raising competence levels
IT support for teleconferences
Scientific literature on/over the Internet
Manuals and information systems available via the Net
Specialized databases on various medical fields.
In Russia, all of this is called "telemedicine". The application of telemedicine has the following primary objectives: diagnosis, treatment, teaching, information services. Distance education is regarded as part of telemedicine only in the cases where telemedicine consultations are conducted for specific patients and / or in specific fields.
Access to Net-based teaching is easy. It is possible to find examples of surgery and consultations on the Net (http://weborto.net/forum); various specialized medical books and journals (http://www.consilium-medicum.com/index/education/books.shtml) and the educational centres themselves (http://www.consilium-medicum.com/index/education/educate.shtml). It is only the prices of Internet access which stand in the way of round-the-clock training.
In August 2001 the Coordination Council at the Ministry of Health and the Russian Academy of Medical Science prepared and signed the "Concept for the development of telemedicine technologies in Russia and plans for their realization". The action plan for realizing this concept includes preparation of an overview of telemedical services, specification of fees and payment, proposal for including telemedicine with other health services where no patient contribution is charged, programme for organization of telemedicine help in a state of emergency / major disasters, and specification of requirements for distance education in further education and post-qualifying education for health professionals.
In May 2002, there was a debate about telemedicine in the parliament. Everybody who contributed to the discussion said that it was time to gather experience from various regions that use telemedicine, summarize them, and recommend a common telemedicine system for the whole of Russia. Everyone agreed that a common standard for equipment and software was necessary. One of the participants, cosmonaut and cardiologist Oleg Atjkov, said: "There is an intellectual product, DORIS, developed by one of our departments." Everyone would like to get all the necessary legal documents in place.
In addition to regulations, laws and documents that cover all health institutions and health professionals throughout the country, regional authorities can adopt regional regulations and provisions. These documents emerge in certain regions because of local funding possibilities, perspective on the problem in question, lobbying, etc. For example, Moscow, St. Petersburg and other large cities have such regulations which function only in their areas. These include "Telemedicine in Moscow county" of 02.07.97, where specific goals and tasks for the introduction of telemedicine in the county are described.
In north-west Russia – an administrative area with 28 million inhabitants, 700 large hospitals and several thousand medium-sized and small ones – there is an independent health council consisting of health leaders from 9 counties. Telemedicine is also on the agenda in this area. The North-West Telemedicine Association works together with both east and west, and has home pages in Russian and English (http://www.telemedicine.ru/).
There is a need for a State programme with the objective of preparing the way for the development and introduction of various types of telemedicine service.
On 5 June 2003 there was a hearing in the Duma on the status and development perspectives for legislation models in the public health service in Russia and the former Soviet Republics. Oleg Orlov proposed that legal aspects in telemedicine and telemedical services should form part of this legislation
Legal aspects of telemedicine
Up to now, telemedicine has been governed by two sets of legislation for two different sectors: (in) health and medicine and (ii) informatics. At the moment, there is no specific law for teleconsultations.
Nor are there specific regulations about payment for consultations or State guarantees that patients will have the right to consultation using telemedicine.
Expenses for the Internet / telephony and travel are two miscellaneous items in the local, regional and State health budget. So there is no direct relationship between relatively low expenses for teleconsultations and high expenses for patient travel, although everyone "knows that telemedicine saves time and money".
The responsibilities of line and service providers as well as the certification of telemedical services have not been clarified either.
The main requirements for legal regulation of telemedicine are the following:
formulation of State policy for telemedicine;
setting up organizational and financial conditions which can contribute to the most efficient use of telemedicine possible;
rights for all users of telemedicine, primarily patients;
regulations which ensure the quality of telemedicine services
Teleconsultations take place between doctor(s) and doctor(s). It is the doctor who is treating the patient who is responsible for the patient, regardless of any second opinion. Both parties are obliged to provide evidence of the correctness of the consultation.
The provider's responsibilities as well as the certification of telemedical services have not been clarified either.
The use of telemedicine technologies in areas other than the public health service, for example the Armed Forces, units mobilized in disasters and states of emergency, require additional regulations.
Telemedicine technology is an important part of ICT in the Russian public health service. Necessary conditions which are mentioned include: a) a common patient database; b) synchronous operation of various communication channels; c) continuous analysis of transmitted patient data with the possibility for subsequent rapid decisions.
Only a shortage of funding sets limits for a major initiative for the development of telemedicine in Russia. Most initiatives can be classified in three main groups: 1) establishment of centres for teleconsultations; 2) development of information networks; 3) development of programs and future solutions. Recognized research and scientific centres are working on the development of image processing programs.
Telemedicine networks build, as a decentralized system, on the principle of functional standardization. Technological development must be goal-oriented with respect to standard protocols for transmission of medical information. This is very relevant because equipment is used from a variety of companies / countries and various communication channels. This makes compatibility of telemedicine equipment and integration of communications systems a complex issue. The vast majority would like to use Russian equipment, communication and solutions. For example, the Laboratory of Cybernetics (http://cyberlab.iatp.org.ua/
), DiViSy (http://www.divisy.ru/index_en.html
) and others
Major challenges include access to the Internet and the transition to digital telephony in the country's regions and outlying districts.
Rapid development in research and science creates the potential for new telemedicine solutions / equipment. Robotic surgery
, low-invasive intervention such as endoscopy at a distance and other creative solutions are standard topics in conference programmes in Russia. The focus is on miniaturization, smart technologies, robotics etc.
The combination of research results in biology and physics based on nanotechnology1 can lead to a leap ahead within IT. For example, 3D photographs of internal organs and systems can replace traditional X-ray examinations.
The need for telemedicine
Because of geographic distances and infrastructure, Russia has a greater need for "medicine at a distance" than for example, densely populated countries in Western Europe or the USA. Patients who need medical help at/from the top level of expertise, as well as their companions, must travel for several days to reach State centres.
Often, there are trips to consultations before admission and to check-up examinations after treatment. That is why particular mention is made of the possibility of using telemedicine to reduce the number of trips. ICT in health / medicine must promote maintenance of the population's health and increase productivity in the health service.
Telemedicine starts with regional pilot projects. All projects can be divided into 1) clinical, 2) teaching-related, 3) analytical and 4) information projects. Clinical projects focus on solutions important for treatment and diagnostics. Teaching projects focus on the use of telecommunications for distance education. Analytical projects concern the evaluation of quality issues, economic and standardization results after the introduction of telemedicine. Information projects consider access to various information sources and the use of communication lines for administrative purposes.
The annual requirement for each of Russia's regions is estimated at one teleconsultation per 1000 inhabitants. Average actual use is a small percentage of this figure.
Shipping in other parts of the globe, research in Arctic and Antarctic regions, the national rail administration
, the Ministry for States of Emergency and others need telemedicine. Russia takes part in many rescue operations in various parts of the world. The All-Russian Centre of Emergency and Radiation Medicine (ARCERM), which has been a WHO CC since 1995, has a flying hospital. This hospital is transported with transport planes, and landed by parachute. It can be assembled in 40 minutes and can admit 50 casualties every hour, operate on them and treat them. The hospital can function for 7 days without extra supplies, insulated and with a comfortable inside temperature regardless of the conditions outside (from -40 to +40 C). The hospital was demonstrated in Iceland, Alaska, and Canada, and has operated in Afghanistan and Antarctica. One imagines that this type of hospital might have a need for telemedicine…