Last years in Ukraine are marked with the long-awaited
beginning of processes of healthcare system reformation, the program
and trends of which are stated in the foundational documents:
- Decree of the President of Ukraine No 186/93
from 31.05.1993 "On the state policy of informatization in
- Resolution of the Cabinet of Ministers No 605
from 31.07.1994 "Problems of informatization ";
- Concept of state policy of healthcare informatization
in Ukraine (approved in June 1995);
- Order of the Ministry of Health of Ukraine No
349 from 15.12.97 "On the top-priority measures on informatization
in the field of healthcare";
- Law of Ukraine "On the concept of national
program of informatization" No 75/98-Вр from 4.02.98;
- Resolution of the Cabinet of Ministers of Ukraine
from 10.01.2002 No 14 "On approval of the intersectorial
program "Health of Nation" for 2002-2011".
According to these documents a substantial role
in the process of reforming the healthcare system is assigned to
informatization and introduction of high technologies described
by a unified term "telemedicine".
On the other hand, the program of development of
family medicine is adopted, which envisages an U-turn of entire
bulky machine of healthcare and its modernization in order to bring
medicine closer to actual and urgent needs of the patient.
It is of interest to try to find the fields of
crossing of these two volume reform programs in order to examine
at their junction the possibilities of increasing the quality of
In many developing countries, as well as in countries
with transition economy, to which Ukraine can be referred, the level
of medical aid in general is not high. There are thereat some clinics
equipped with modern medical equipment and possessing a staff of
highly qualified specialists. As a rule, such clinics are located
in large cities and not evenly spread over the country's territory.
Thus, a significant majority of the population is forced to use
medical aid of insufficiently high quality, provided by local medical
institutions, the manning level and equipment of which are often
As a rule, diagnosis and treatment of ordinary
diseases give no problem to local specialists; however, in the cases,
when they have to face situations beyond their professional capabilities,
an information vacuum appears, resulting in either wrong or incomplete
diagnosis or wrong techniques of patient's treatment.
Thus, a serious problem of providing doctors of
family dispensaries and remote aid posts with information and consultation.
The most severe this problem becomes for rural regions. Right here
the colleagues working in specialized medical institutions and possessing
vast diagnostic and curative experience can and must give a hand
to a family physician.
The only way to unite in the struggle for patient's
health the efforts of a family physician and diagnostician, separated
by a distance, is telemedicine. Creation of telemedicine network
within the scope of the program of family medicine development enables
beforehand trained staff of family dispensaries to obtain and transmit
to a Remote Diagnostic Center (RDC), created on the basis of one
of the leading regional medical institutions (as a rule, these are
district cardiological dispensaries or diagnostic centers, in fewer
cases - district clinical hospitals), digitized information. This
information can be recordings of electrophysiological signals, for
example, ECG or EEG, scanned X-ray images, electronic medical records,
including case history, etc. Basing on obtained information, the
highly qualified specialists of an RDC can:
- make a correct diagnosis;
- consult family physicians in questions connected
with the technique and specific features of treatment of diagnosed
- make a decision on the necessity of immediate
admission of a patient to a corresponding medical center;
- provide remote consulting support of a patient
after a diagnosis is made or a patient is discharged from a hospital.
The best developed of all areas of practical telemedicine
in Ukraine, as well as in other countries, is remote transmission
of ECG. It can be carried out in two ways. The first one supposes
that a family physician possesses a 3/6/12 channel portable electrocardiograph,
usually equipped with thermal printer and LCD screen and has a possibility
of not only record, print out and process a patient's ECG, but also
to transmit a data file via modem by means of digital communication
protocols to an RDC's computer. An example of such device in Ukraine
is electrocardiograph "UCARD-200" manufactured by "UTAS",
The other approach supposes that the transmitting
side has a pocket-size telemetric electrocardiograph-transmitter,
which can combine recording of one or several electrocardiograms
of a patient with immediate or postponed transmission of a signal
over a telephone line to an RDC. In this case there is no necessity
to have a modem at the transmitting side. All functions of digitizing,
compression and transmission of EEG signal are performed by a microprocessor
built in the electrocardiograph. This approach is implemented in
Ukraine in 12-channel digital system "TELECARD" manufactured
by " TREDEX Ltd", Kharkov.
This approach assumes the involvement in the telemedical
network not only family physicians, but patients themselves, as
the price and simplicity of usage of the peripheral device makes
it affordable for the population. Thus, patients obtain a possibility
to transmit their ECG to an RDC and immediately obtain a consultation
from a specialist. In emergency cases a diagnostician can make a
decision on immediate hospitalization and send to a patient a specialized
ambulance car. In this case the system can perform continuous ECG
monitoring and enable the ambulance car team to talk to doctors
of RDC even during the patient transportation to a medical institution.
It must be noted that both considered systems can
work via both conventional communication lines and on the basis
of mobile phones of NMT, GSM-900 and GSM-1800 standards. However,
for this either an external modem or a mobile telephone with built-in
modem must be connected to the "UCARD-200" system.
It seems necessary to underline those practical
results, which a wide implementation of telemedicine in medical
- dramatic increase of the outpatient and inpatient
medical care to patients in any region of the district;
- providing consultation assistance to medical
workers working in central regional hospitals and family dispensaries
arbitrarily remote from an RDC;
- shortening the duration of temporary invalidity
and disability retirement due to timely emergency medical aid;
- reducing the number of primary and secondary
myocardial infarctions in patients either provided with personal
peripheral devices, or attended by a family physician possessing
such device, and as a consequence, reduction of the number of
unmotivated hospitalizations and visits to polyclinics;
- reducing the number of false calls of cardiological
ambulance teams, which mounts up to 30 per cent of the total amount;
- remote control over the consumption of medication
- plummeting of the cost of qualified medical
aid obtained by patients due to elimination of intercity travels.
In spite of the fact that, at first glance, telemedicine
has bright prospects in Ukraine, in the course of introducing telemedical
technologies in actual medical practice in Ukraine, one regularly
encounters two kinds of delusion: "telemedicine - it is too
complex" and "telemedicine - it is too expensive".
Besides, there is a certain scepsis of doctors regarding the usefulness
of the aid from a doctor dozens and hundreds kilometers away.
The desire to gain an understanding of these delusions
has become one of the incentives to write the present article.
The first thesis: "telemedicine technologies
are too complex and distant from practice". It is difficult
not to agree with this thesis by imagining the reaction of a rural
doctor offered to install a computer, connect peripheral equipment
for videoconferencing (video camera plus image processing board),
use a modem for connecting to the Internet and so on. Note, all
this without abandoning actual medical practice and patients, who
need aid right here and now. It is worth to specially underline
that one-time or even spaced out for a couple of years provisioning
with all or at least a major part of rural outpatient medical rooms
with a complete set of above mentioned equipment looks like an utopia
requiring no proves.
The second thesis: "telemedical technologies
are too expensive even to think about". Properly, it follows
from thesis one, as the estimated cost of the "necessary",
as they usually claim, set of equipment is more than ten thousand
grivnas. One must add to this the cost of a dedicated communication
channel, without which a doctor can only exchange email messages,
and even this with great difficulty, as the quality of rural telephone
networks leaves much to be desired. The Ukrtelecom prices for a
dedicated line are 800 grivnas for connection and about twenty grivnas
- monthly subscription fee. Besides, it is necessary to pay a provider
company, which provides the access to the Internet over a dedicated
line. Minimum prices are in the order of 140 grivnas monthly, including
up to 100 Mb of prepaid traffic. All that is above - at rates of
70-80 kopeks/Mb. To this we add that 100 Mb - it is approximately
15-20 minutes of compressed color video. How many videoconferences
one can hold for this money?
So, the reasons for scepsis of a rural doctor become
more than understandable. And further, if we take into account that,
as a rule, he has at his disposal no diagnostic device, which can
provide the input of digital information into a computer, the situation
seems simply desperate. However, active advocates of such telemedicine
can propose, for example, to print out an ECG on a one-channel electrocardiograph
of 'Malysh" type, glue strips to a sheet of paper, scan the
image and safely send it by electronic mail to a remote diagnostic
center:Perhaps, it is easy to imagine, what a dispensary doctor
will think about such kind of consultative aid. However, of no better
opinion on telemedicine in such implementation will be a diagnostician,
who has used to work with a decent quality electrocardiograms, as
a rule, multichannel, recorded on a more or less modern equipment.
So, there is no way out? All that is left is to
day-dream and wait, when Ukraine will become so rich that it can
find budget means to purchase telemedical working places for each
family dispensary and each rural medical aid post, that in one beautiful
moment the access to the Internet will become cheater and all rural
telephone lines will become digital?
No, far from true, but to understand this it is
necessary to discard stereotypes, imposed by dilettantes from telemedicine,
who have chosen form all diversity of this trend only that, which
makes it possible to number themselves with advanced users of the
most complex modern technologies. It did not go without bureaucrats
from telecommunication authorities, who have seen in word "telemedicine"
the known suffix "tele-", but totally lost the medical
contents. However, they can be forgiven for that due to peculiarities
of exceptionally technical education and posts held. And all this
'feast pf progress" has been picked up by mass media, greedy
for sensations and vivid presentations. As a result, the notion
of "telemedicine" first of all is associated in Ukraine
with video conferences and telebridges, with the possibility not
only to hear, but also to see a conversation partner hundreds of
Indisputably, this is interesting, it makes it
possible to hold useful meetings, train remote subscribers, exchange
opinions, including on specific features of diagnosis and subsequent
treatment of patients. But such telemedicine has no serious social
basis, these are and will be for a long time one-time actions, enthusiastically
described by mass media, but are not able to change the actual state
of the matters in Ukrainian healthcare. One must be aware of that.
Leading central and regional medical centers can
afford buying videoconferencing equipment, connection and regular
usage of dedicated communication channels, telemedical consultations
with foreign clinics on the basis of exchange of laboratory investigations,
digital and video images, electronic medical records, etc. Even
in spite of the fact that there is virtually no serious state approach
to the development of telemedicine, a number of Ukrainian clinics
already use these technologies in their practice, actively cooperate
with foreign partners and even take part in the process of patient
Nevertheless, this is only the top of an iceberg.
At the same time, in the country there are thousands of dispensaries
and aid posts, which service millions of patients, and for them
such telemedicine remains the technology from another world. Meanwhile,
in Western countries long ago has become an axiom the fact that
telemedicine is intended just for remote, difficult to access places,
deprived form quality diagnostic aid, at places, suffering from
the lack of highly qualified medical staff. Just drive outside the
girdle road of any Ukrainian district center, and you will find
yourself in such places.
The main purpose of telemedicine - increasing
the quality of diagnostic and consultation aid to the population
with cardinal sparing of costs. This is just the main advantage
of telemedicine. That is why all developed countries devote increased
attention to the development of telemedicine technologies. Russia
also went this way, and here the program of development of telemedicine
has been already composed and begins to be implemented, telemedical
centers are created everywhere, standards are introduced, fund "Telemedicine"
and the Coordinating Council on telemedicine of the Ministry of
Health. Serious steps are undertaken in implementing telemedicine
at the lowest level of healthcare, the closest to a patient. At
the state level the telemedicine is recognized as one of three main
trends of social implementation of telecommunication technologies.
Unfortunately, the telemedicine in our country
develops at the risk and peril of the most enterprising and progressive
managers of medical institutions, as well as at the expense of initiative
developments of domestic manufacturers of telemedical equipment.
Nevertheless, there are some achievements, and the medical public
at large must be made aware of them. However, before to proceed
to the description of actual achievements in the field of telemedicine
introduction in Ukraine, it is necessary to try to formulate the
basic requirements to telemedical equipment in the most rigid wording:
- Ensuring least cost when creating a consultation network.
- Providing the highest level of diagnosis compared with any
- Providing real practical consultative assistance to doctors
in remote dispensaries.
- Simplicity of usage and reliability of operation.
In the case when at least one of these requirements is not satisfied
the prospects of implementation of telemedical systems seem rather
limited due to extremely cautious attitude to this trend of the
country's medical authorities and doctors.
The telemedical system of ECG transmission over
telephone "Telecard" is widely used in Ukraine. In a number
of districts the stations are installed in district cardiological
dispensaries, diagnostic centers and district clinical hospitals.
Most widely the system is used in Kherson and Sumy districts, where
the "Telecard" peripheral devices are installed in all
central regional hospitals.
The system has found an interesting implementation
at Nizhnedneprovsky tube plant, city of Dnepropetrovsk, where a
central station is installed in the factory's medical aid post,
and the peripheral devices are located in the most remote places.
During three years of operation several infarctions and considerable
number of rhythm disturbances of various degree of severity have
been registered there. Besides, the system is used at regular health
survey of the plant's employees, which has made it possible to avoid
queues in the medical aid post. ECGs of the employees are transmitted
directly from the shops.
In the Kharkov Central Clinical Hospital No 5 the
"Telecard" system operates for more than five years. Peripheral
devices are installed in several departments of the hospital, in
a number of railroad hospitals, at two cars of the city ambulance
aid, as well as in the Interdistrict hospital of the Penalty Execution
Administration. Several devices are used privately. The employees
of the Remote Diagnostic Center analyze daily dozens of electrocardiograms,
providing qualified diagnostic and consultation assistance to their
colleagues and patients.
At the end of 2002 the Kharkov district clinical
hospital joined the program of telemedicine implementation into
medical practice. At present a central station is installed in the
department of functional diagnostics (DFD), but it is planned to
create in the nearest future a round-the-clock service. Three peripheral
devices are installed in departments of the district clinical hospital,
which has made it possible to reduce substantially the number of
calls of DFD staff for ECG recordings in these departments. Operational
efficiency of ECG recording has increased, together with the increase
of diagnosis quality, because the "Telecard" system makes
it possible to record and transmit 12-channel synchronous ECG with
the duration of 15 seconds.
The used original know-how developed by the manufacturer
of the system, company "TREDEX", ensures digital transmission
of ECG over any telephone lines and even over mobile communication
channels of GSM standard without using additional modems. At the
same time, when DFD staff is called for ECG recording, one-channel
electrocardiographs are used, which are much inferior to "Telecard"
in the quality of electrocardiogram displaying.
To the credit of employees of telecommunication
administration of Ukraine, one of the most coherent and active supporters
of telemedicine introduction in Kharkov district is the director
of Kharkov directorship of "Ukrtelecom" open joint stock
company S.I.Tatarchuk. With his support, the first in Ukraine experiment
on equipping family dispensaries and rural aid posts with "Telecard"
peripheral devices develops in the district. So, the equipment already
works in Kharkov region - in Ponomarenky, Manchenky, Korotich, Liptzy
and Merefa. More than one hundred electrocardiograms were received
over a short period, a substantial part of which had pathologies.
As many patients acknowledge, they never accounted on the possibility
of obtaining consultation from the best specialists of Kharkov district
without leaving the native village.
The results obtained in the course of first months
of the "Telecard" system operation have strengthened the
assurance of the developers, Chief Physician of the District Clinical
Hospital N.I.Berezka and district medical authorities in the correctness
of the made decisions. At present negotiations are in progress for
installing "Telecard" devices in other family dispensaries
and aid posts of Kharkov district as well.
It is of interest to analyze the system possibilities
basing on the specified criteria of efficiency of telemedicine equipment.
1. Ensuring the lowest cost.
The cost of the "Telecard" central system
is 13,500 Grn, each peripheral device costs 3,000 Grn. The cheapest
one-channel electrocardiograph costs not less than 5,000 Grn.
Thus, when, for example, 20 medical aid posts the
expenditures on "Telecard" will be 73,500 Grn. For purchasing
one-channel electrocardiographs they will be 100,000 Grn, that is,
the saving will be 26,500 Grn.
2. Ensuring the highest level of diagnosis compared
with any other non-telemedical equipment.
In order to make a correct diagnosis and develop
proper technique of patient's treatment, a doctor must be of high
qualification, including the field of electrocardiography. Training
of each doctor at the initial level, only to teach him or her to
at least slightly understand ECG, will cost not less than 300 Grn.
For 20 medical aid posts - 6,000 Grn.
But even after that the level of diagnostic skill
of the leading specialists of the district, receiving ECG over telephone
from regions, remains immeasurably higher than the level of qualification
of local specialists. And this means that there is no alternative
to telemedicine in the course of solving the task of increasing
the level of medical aid to the population. No other non-telemedical
equipment can ensure a quality diagnosis over 2-3 minutes.
3. Providing actual practical consultation assistance
to doctors of remote dispensaries.
The experience, which the developers of the "Telecard"
system possess, large number of favorable responses and continuously
growing volume of transmitted ECGs have unambiguously shown that
doctors in the field have apprehended with enthusiasm the prospects,
which opened before them and try to use "Telecard" regularly
in their work.
4. Simplicity of usage and reliability in operation.
During seven years, which have passed since the
first version appeared, "Telecard" have passed through
four modifications aimed at simplifying its operation and ensuring
reliable operation over any communication lines, including very
noisy ones. Over the last two years none at all warranty or post-warranty
repair of the equipment took place, in spite of the fact that hundreds
of devices work in the healthcare system of Ukraine.
As to the simplicity of usage, the device weights
130 gram, is pocket-sized and provided with a single button, which
switches all modes of the device operation. The operating instructions
occupy one sheet of paper of format A4. Average time of training
to operate the peripheral device - 5 minutes. The most time-consuming
is the training of medical staff in proper application of ten electrodes
simultaneously, as, unfortunately, the overwhelming majority of
specialists of dispensaries and medial aid posts never encountered
12-channel electrocardiographs in their work.
In addition to item 1 of this estimation, the calculations
can be given made in the district cardiologic dispensary of Kherson
district. One visit of an emergency team from Kherson to a district
region at a distance beyond 200 km costs 700-800 Grn. Not less than
20-25 per cent of calls were false in the sense that a provisional
diagnosis "myocardial infarction" or another diagnosis,
which require immediate admittance to the district clinical dispensary,
made by doctors in regions, was not confirmed. In these cases the
patients can be treated in central regional hospitals.
Implementation of "Telecard" has made
it possible to eliminate such unjustified calls virtually completely.
Thus, with one peripheral device costing 3,000 Grn and with the
given expenditures on one visit of the emergency team, "Telecard"
pays off already after 4-5 cases of canceling such calls, that is,
virtually, in one or two months.
The results given in the article must be considered
as an invitation for a dialogue to the specialists, who determine
the development of telemedicine in regions. As the calculations
and work experience show, implementation of telemedicine in actual
medical practice is not a tribute to fashion at all, but a way to
increase the quality of medical aid with cost saving. There is no
alternative to telemedicine from this point of view.