Translated by
2019/07/11 15:07:22

Telemedicine (Russian market)

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Content

In Russia telemedicine as public medical practice only begins to develop though for the country with huge distances and transport backwardness telemedicine services have especially important social and economic value.

Telemedicine can be used for remote audio-and video consultations, reduction of costs for repeated visits to the doctor, permanent monitoring of patients with chronic diseases, remote surgeries, the urgent help at emergencies, the help to military and astronauts and also for training and advanced training of doctors.

Telemedicine has two views: "doctor-doctor" and "doctor patient". And if the first is also actively used long ago in Russia, then before the second there are serious calls. In general the patient can see a doctor remotely already now – for example, to direct analysis results after internal primary survey or to consult with the famous specialist from other city on Skype.

Problem that legal status of such consultations is up to the end not defined. The patient cannot be sure that the doctor will bear responsibility because of incorrect council, and doctors cannot make the diagnosis or to appoint treatment[1].

Telemedicine: future of health care

Основная статья: Telemedicine: future of health care

What calls face telemedicine in Russia

The first problem – availability of modern technologies to the population.

Not in all Russia gas and electricity, not to mention the high-speed Internet and a qualitative audio-and video equipment are carried out. If to connect clinic to the reliable Internet and to reduce telemedicine prior to a conversation with the doctor from the local regional center or Moscow, then inevitably there will be a question of efficiency – as this doctor of the patient will treat if it from it in 100 km? And whether this doctor will just duplicate the local paramedic what is excessive at already modest expenses on medicine?

There is no confidence also that elderly people will be able easily to seize the same Skype – and if communication is interrupted or something will break? Meanwhile these risks outweigh possible advantage of telemedicine, however, perhaps, the optimal solution will be found soon. Moreover, the patient can not always buy the necessary equipment.

The second problem – security issues.

Of course, it would be very convenient to create full-fledged uniform medical base across all Russia with the accessibility in it any doctor, but how to be convinced that this base is well protected, and data in it are reliably ciphered? The doctor can find confidential information about a normal video call – how to check that it will not be intercepted? And how to be convinced that it is used legally and cases that to pensioners with mental frustration "black realtors" in large quantities appeared suddenly are impossible? So far it is single risks, but they can become a serious problem if telemedicine is used everywhere.

The third – readiness of doctors to work with telemedicine.

Doctors reluctantly accepted a computerization of clinics. Many specialists hardly studied use of computers that led to delays in service of patients and to quality degradation of acceptances. The doctor cannot pay sufficient attention to the patient if a half of acceptance goes on input to the computer of passport data. Telemedicine technologies are more difficult in application, and risks from adoption of the wrong solution increase. Also social effects of implementation of telemedicine for doctors are important – theoretically it can lead to reduction of already not numerous clinics in the remote regions, and it means that some doctors can appear without work.

The fourth – trust of patients to telemedicine.

All got used to classical medicine, it causes trust and how to be with teleconsultations with the doctor from other region? Especially if to consider that the conservative-minded people with mistrust belonging to new technologies often address to clinics. The expert considers that the trust of patients to telemedicine can be gained showing on a real example that in online consultation there is a value, and to remotely receive answers to questions of health really. The more often people will receive the high-quality help from high quality doctors, the quicker telemedicine will become a worthy alternative to search of symptoms on the Internet. But you should not forget and about nonconventional medicine and charlatans – complete legalization of telemedicine without serious control over it can lead to blossoming of alternative specialists. Besides, telemedicine should not be perceived as defective medical consultations or "medicine for the poor". Otherwise queue will only grow by internal acceptances because all will think, what is so more reliable.

2019

Telemedicine lacks people, freedom and demand

On July 11, 2019 it became known that telemedicine services are successful in Russia only within separate projects. At the same time the most important elements of telemedicine services - such as electronic consultations, electronic sick-lists and recipes - are separate and are often incompatible with each other.

As the head of digital medicine of Invitro LLC Boris Zingerman noted, one of important tasks in the field of telemedicine is determination of those cases in which providing telemedicine primary survey is possible. At the same time, according to Boris Zingerman, telemedicine is a service which certainly is necessary to patients and, most likely, the medical organizations.

In turn, the chief physician of Federal State Budgetary Institution NMITs endokrinologii Ministry of Health Russia Natalya Mokrysheva said that the main problem of telemedicine is the personnel. Also she paid attention that the center brings up a question of payment state of those telemedicine consultations which have the doctor-doctor model.

«
In the compulsory health insurance system tariffing of teleconsultations is absent. There are only separate regional programs, the VHI programs and arrangements, profitable to the companies. Consultation on the doctor patient model is beyond the law to this day. Owing to what doctors have no legal ground and an opportunity within telemedicine services to advise the patient, to make it the diagnosis, to write out the recipe, to give appointment,
specified Natalya Mokrysheva
»

As other problems of telemedicine she called need of confirmation of the identity of the patient and doctor via the portal of state services and the electronic digital signature; absence for the organizations of the telemedicine help of infrastructure in many regions; absence for telemedicine consultations of rates of compulsory health insurance in many regions.

At the same time Natalya Mokrysheva noted that, despite the financing, in general the possibilities of equipping and communication with the chief regional specialists which are available for them selected to regions for equipment, they belong to telemedicine development half-heartedly.

«
There is no message from doctors of regions to contact those specialists who could give, for example, to them this or that advice
commented Natalya Mokrysheva
»

The CEO of Doctor ryadom LLC Denis Shvetsov paid attention to the following: what is declared within telemedicine and that becomes - it is absolutely different things.

«
We declare that telemedicine should give access and increase access to primary medical care and increase availability of narrow specialists. At the same time in practice we prohibit doctors to hold primary consultations in telemedicine, we prohibit them to make diagnoses and to appoint treatment,

»

At the same time, he noted that for medical clinics telemedicine is first of all increase in expenses on information technologies, additional training of doctors and impossibility to attract clients.

«
Primary consultations are prohibited, and it is possible to hold, in fact, only repeated consultations which and without telemedicine in clinics become. At the same time the average bill of telemedicine services is significantly lower, than at internal acceptances. Patients are rather inert in the behavior, and in particular - in consumption of medical services,
noticed Denis Shvetsov
»

Besides, Denis Shvetsov noted that such basic elements of telemedicine services as electronic consultations, electronic sick-lists and recipes are incompatible with each other, being separate.

«
the Doctor advising online the electronic sick-list cannot close. And appointing treatment, cannot give the electronic recipe,

»

It also provided some data on demand of telemedicine company services "The doctor nearby": "There are cases when our telemedicine services are not used by partners at all. At the same time within cooperation with some other partners their use reaches 100%, and in a case with one partner - even 150%. At the same time also the number of repeated consultations is indicative. If the person addressed once, then afterwards he will already constantly address".

As the tool capable to increase interest in telemedicine in Russia, he suggested the Ministry of Health to be more courageous in those changes which are carried out (connected with telemedicine) and to give the chance to private players to get access to large audience thanks to pilots of the ministry of these or those telemedicine services for the purpose of assessment of their usefulness[2].

As telemedicine in Russia after its legalization develops

On January 25, 2019 survey results of Ondoc service which showed the weak interest of health facilities in telemedicine services were published. 72% of the polled clinics announced implementation of remote consultations in 2018 (then the law on telemedicine legalization began to work), but only 67% are ready to continue development of projects in the 2019th.

112 representatives of medical institutions of Moscow, St. Petersburg, the Central, Siberian, Volga, Northwest, Far East and Ural federal districts and also the Crimea participated in a research. Of them 95% were made by representatives of private clinics.

The law on telemedicine did not contribute to the development of the industry, and, on the contrary, led to loss of interest in it from medical institutions
The law on telemedicine did not contribute to the development of the industry, and, on the contrary, led to loss of interest in it from medical institutions

For maintenance of clients telemedicine is used by 55% of clinics,  for mass consultations via aggregators — 45%, within insurance policies — 9%, for another — another 9%. 55% of respondents reported that they monitor customer satisfaction level telemedicine consultations. 67% of top managers of clinics consider that telemedicine consultations are in demand.

Ondoc paid attention that representatives of clinics expected much more demand for telemedicine services.  According to the representative of Ondoc Jana Kubrick, by the beginning of 2019 remains not until the end of adjusted as the law on telemedicine which became effective the previous year still is improved using bylaws.  5% of survey participants said that for 2018 they were disappointed in telemedicine.

The representatives of private clinics polled by Kommersant also consider that development of telemedicine is interfered by a number of legislative barriers. If the authorities settle a possibility of remote diagnosis, telemedicine services will be in great demand, consider in Medsi. According to the managing partner "The doctor nearby" Maxim Chernin, joint efforts of market participants are necessary for development of the legislation.[3]

Telemedicine needs updating of the regulatory base

Acting normative - the legal base is insufficient for implementation of telemedicine technologies in the Russian medical organizations. The Accounts Chamber of the Russian Federation came to such conclusions, having studied practice of use of telemedicine technologies in 2017-2018. According to observations of auditors, the Ministry of Health does not conduct statistical observation of implementation and use of telemedicine technologies. Respectively, it does not allow to make timely management decisions on development of practice[4].

The Accounts Chamber found out that in two last years regions did not receive funds from the federal budget for services using telemedicine technologies. "This help was paid within territorial programs of compulsory health insurance, - the auditor of JV Mikhail Men reported. - The corresponding expenses in 2017 in 17 subjects of the Russian Federation made 21.2 million rubles, and in 2018 in 20 regions - 18.8 million rubles".

2018

The rating of districts on demand of telemedicine

From March to October, 2018 the greatest number of requests for telemedicine consultations arrived from Central Federal District — 25% of a total quantity. On December 5, 2018 reported about it in Sberbank. The Moscow region (Moscow and the Moscow region) of which 54% of a total quantity of addresses in the district were the share became the absolute leader in the number of addresses to the CFD. The five of areas where telemedicine was the most demanded, included the Lipetsk region (6% of calls) and also the Bryansk, Voronezh, Tula and Yaroslavl regions (on 4% of calls). Read more here.

Rostec and the Ministry of Health will connect to a single system of telemedicine of 700 medical institutions of the country

National center of informatization (NCI) of State corporation Rostec and All-Russian center of medicine of accidents Protection Ministry of Health Russia was announced on November 20, 2018 agreement signature about cooperation. Completion of formation of the Russian telemedicine infrastructure will become the first joint project of the parties. Until the end of 2018 to the system of telemedicine it is going to connect more than 700 medical institutions in all regions of the country. In more detail here.

2017

The Ministry of Health developed an order of rendering the telemedicine help

The Ministry of Health described an order of rendering remote medical care. The document does not set responsibility[5] for operators because of whose low-quality work harm[6] can be done to the patient]

Purposes and terms

The Ministry of Health prepared the draft of the order setting an order of the organization and delivery of health care with "use of telemedicine technologies". RBC studied the document, its authenticity was confirmed by two sources in the market which received the document from the Ministry of Health. It defines rules of providing the telemedicine (remote) help to patients and remote interaction of medics among themselves. The Ministry of Health should approve its final version by the order which will become effective since January 1, 2018.

Rules of use of telemedicine technologies both between the doctor and the patient, and between doctors are stated in the project. In the first case telemedicine is going to be used for prevention, collecting and the analysis of complaints of the patient, data of the anamnesis, observation of state of his health, correction of the treatment which is earlier appointed on internal acceptance and also for the decision on need of personal acceptance, the document says. The document does not allow to make the diagnosis remotely.

If one doctor remotely advises another, the order allows doctors to set and adjust the diagnosis. They can estimate the patient's condition, specify tactics of inspection, treatments, etc.

The telemedicine help will be as free, within compulsory health insurance and other state guarantees, and paid. Features of payment of such help in the document are not registered.

All medical institutions and doctors who are going to render remote consultations should be registered in a single state information system in the field of health care (Uniform State Health Information System). Requirements to communication channels, information security tools and also the technical and software tools used at telemedicine consultations, the Ministry of Health will register separately, the document says. ​​

The document also claims what information medical institution and doctors will have to provide to the patients who are going to address them for telemedicine consultation. The patient will be able to learn an experience of the doctor, his scientific degrees and prior workplaces.


Contradictions and inaccuracies

In the draft of the order communication methods between the doctor and the patient are described, but in this part of the document there is a contradiction. According to one point patients and doctors will be able to communicate through audio-or video conference and also using electronic messages. In other point it is specified that consultations in real time (discussion of a current status of the patient) are possible only when using the telemedicine equipment and a video conferencing. The Ministry of Health did not report RBC what point reflects a position of department and what should consider priority.

Putin signed the law on telemedicine

At the end of July, 2017 the president Russia Vladimir Putin signed the law on telemedicine providing the statement of electronic recipes and a possibility of rendering remote medical assistance.

According to the text of the document published on the official portal of legal information, doctors will be able to help using modern technologies by carrying out remote consultations and consultations and to monitor the state of health of the patient, including online.

Russians will be treated on the Internet: Putin approved the law on telemedicine implementation
Russians will be treated on the Internet: Putin approved the law on telemedicine implementation

Also physicians will have an opportunity to issue recipes (including on the drugs containing psychotropic substances and drugs) in the form of electronic documents. During remote work medical institutions will use information on patients from a unified identification and authentication system.

The law provides a possibility of issue of recipes on the medicines including containing drugs or psychotropic substances, references and recipes on medical products in electronic form. The right to choose a form of the recipe remains for the patient.

The law on telemedicine is drafted within implementation of the priority project "Improvement of Processes of the Organization of Medical Care on the basis of Information Technology Implementation" ("Electronic health care") and provides creation of the legal basis of use of information telecommunication technologies in the field of protection of public health.

The law becomes effective since January 1, 2018.[7]

The prime minister Dmitry Medvedev approved the bill in May, 2017. According to the head of the government, thanks to a single system "access to information, necessary for treatment, will be possible from any medical institution", and citizens should not wear with themselves "a kippah of papers" any more.

The State Duma prohibited doctors to make the diagnosis by video conference

On July 20 it became known that the State Duma approved in the second reading the bill of use of IT in medical care of citizens. According to the document, the doctor can advise patients far off, by video conference, however has no right to make the diagnosis during such consultation, as well as to appoint treatment — at least if sees the patient for the first time.[8]

The initial version of the bill prepared by the Russian Ministry of Health also did not permit to make the diagnosis far off. However before submission of the document the point which it allowed was added to the government in it. After consideration of this version of the bill in the first reading in June, 2017 deputies of the State Duma proposed a number of amendments. In particular, one of amendments imposed ban on a possibility of remote diagnosis again. It is expected that the law on telemedicine will become effective since the beginning of 2018.

Photo: www.medmix.at
Photo: www.medmix.at

What is allowed by the law

According to the current version of the bill, doctors can hold telemedicine consultations and consultations with each other, with patients and with official representatives of patients. At the same time the personality of participants of a session should be confirmed using the digital signature or authorization on the portal of state services, and all actions during consultations — to be documented.

By video conference the doctor can write out the reference or the recipe, including on medicines of narcotic or psychotropic property and to issue them in electronic form. Digital recipes will directly be sent to the pharmaceutical organizations. However the patient will have right to select a method of obtaining the recipe — from a paper or electronic form. Regulations on electronic recipes will become effective since the beginning of 2019.

The patient at the very first address an appointment with the doctor by video conference is obliged to make on internal acceptance. During internal acceptance the doctor will perform inspection, will make the diagnosis and will appoint treatment. After that to watch a status of the patient and he will be able to adjust a treatment technique already by video conference.

The bill of the Ministry of Health of telemedicine is sent to the State Duma

In April, 2017 the bill from the Russian Ministry of Health of use of ICT in health care was supported by the government commission on lawmaking. After the approval by the government, the document will be sent to the State Duma of the Russian Federation.

The commission of the Government of the Russian Federation approved the bill of the Ministry of Health of telemedicine. It is expected that the State Duma will approve it in the first half of the year 2017.

As noted on the official site of the Government of the Russian Federation, the document "it is designed to create the legal basis of use of ICT in the field of protection of public health".

"In particular, the possibility of rendering medical aid using telemedicine technologies by carrying out the consultations and consultations providing remote interaction of doctors among themselves, the doctor and the patient or his legal representative and also remote monitoring of the state of health of the patient is provided" — it is specified in an explanation to the bill.

The new document also makes changes to such laws as "About bases of protection of public health in the Russian Federation", "About drugs and psychotropic substances" and "About drug circulation".

According to it, creation of the Single state information system in the field of health care in which all data of the medical organizations and public authorities in the field of health care will be accumulated is supposed, providing formation of medical records of patients in electronic form and maintaining the existing federal registers of the persons sick with separate diseases. Thanks to an innovation will be and process of determination of need for provision of medicines is more effectively smoothly running. The bill assumes also transfer to a digital format issue of recipes on medicines and the references.

The document was created by the Russian Ministry of Health within the "Improvement of Processes of the Organization of Medical Care on the basis of Information Technology Implementation" project ("Electronic health care"). On October 25, 2016 according to the results of a meeting of presidium of Council at the President of Russia for strategic development and priority projects its passport was approved.

The head of service " Yandex.health " Grigory Bakunov positively speaks of the new bill:

"We positively estimate news about approval of the bill of the Ministry of Health as it allows to hope that already in the nearest future telemedicine in Russia will be resolved legislatively. On information which is available for us, the bill in the current type permits not only remote communication of doctors among themselves, but also remote consultations of patients with doctors, and in it are considered industry wishes which were reflected in earlier offered bill".

Speaking about the bill of the Ministry of Health, the associate director of IIDF on the legal issues Iskender Nurbekov pays attention to defects. So, according to him, in the document there is no clearness in such question as what service the patient can receive, remotely consulting with the doctor, there is no accurate information that it will be authorized to do to the doctor remotely. The expert says: "In edition of the bill of the Ministry of Health use of technologies for interaction of doctors, consultation of the patient and monitoring is supposed, but a concept of medical consultation it is not recorded. There is no clarity whether the doctor will be able to appoint or change treatment remotely. Besides, interaction of the doctor and average medic for remote treatment is not stated in the bill of the Ministry of Health. Today the medical personnel of medical and obstetrical centers can not always appoint the qualified treatment for patients. If not to resolve this issue today, in the near future points will not be able to service properly patients, death rate in hardly accessible points can grow. The mechanism of the "simplified" identification by doctors, for example, via the portal of state services and the SMS notification is not registered". Nurbekov notes that the telemedicine purpose – to provide operational interaction between the doctor and the patient.

In 2016 the bill of use of ICT in health care was developed and submitted to the State Duma by the Institute of Development of the Internet (IDI) with the assistance of the Internet Initiatives Development Fund (IIDF) and Internet Yandex Company, but a year later was not considered. According to Nurbekov, such document is very important both for medicine, and for the Internet industry because availability of medical services is insufficient.

"It is vital that the relations between the patient and the doctor were set so that the person in need in the help could receive the qualified medical service. We consider that two bills have identical subject and should be considered at the same time according to regulations of the State Duma, then both the opinion of representatives of the industry, and opinion of the regulator of the market will be considered. The decision on it is made by the State Duma", – he emphasized.

Opening of the first telemedicine mini-office in Moscow

On April 5, 2017 it became known of opening in Moscow of the first mini-office for telemedicine provision of services. It will open in Moscow in the second quarter 2017 and will be located in one of shopping centers, reports the agency of city news Moscow with reference to zaveduyushchgo department information and Internet technologies of the First Moscow state medical university of I. Sechenov Georgiya Lebedeva.

«
At the end of April beginning of May only one office will be started so far, and we will look as far as it is effective and it is useful. It will be an experiment, today there were no similar precedents still — Lebedev noted.
»

The place of opening of the Moscow\'s first telemedicine mini-office defines shopping center
The place of opening of the Moscow's first telemedicine mini-office defines shopping center

According to him, the first telemedicine office will be based in one of large shopping centers in Moscow. In what building there will be this office, Lebedev did not specify and only added that it is about shopping center which "precisely will be in the center of Moscow where there is a large number of visitors".

It is planned that at "mini-office" one general practitioner will advise patients. He will make the decision what specialist needs to be invited for consultation and what else to carry out procedures to receive confirmation of the diagnosis. Each consultation will last about an hour.

According to Georgy Lebedev, the university will check work of staff of mini-office of telemedicine, namely how they will advise patients.

«
We will provide monitoring of this process that it went with advantage for accomplishment of medical functions and that there was an opportunity to be connected to process, to consult the patient qualitatively and competently — he explained.
»

In the future in the capital it is going to open still offices of telemedicine if the mini-office is effective and useful.

By the beginning of April, 2017 the law on telemedicine is still not adopted. Two different bills on this subject are discussed – one of them is prepared by the Ministry of Health, the second — Institute of development of the Internet, Internet Initiatives Development Fund and "Yandex".

The NCI, 1C and profile scientific research institutes create consortium

Main article: Network Telemedicine Express of Mini-clinics (NTEMC)

At the beginning of 2017 the consortium of the organizations within the project of creation of "Network Telemedicine Express of Mini-clinics" (NTEMC) which should be equipped with the modern telemedicine equipment and the specialized domestic software is created.

2016

Bill of the Ministry of Health

In April, 2016 it became known of development by the Ministry of Health of the Russian Federation of the bill of telemedicine legalization. Innovations can become effective in 2017.

That the Ministry of Health is going to enter into the legal framework of service of remote medical care on the Internet, Vedomosti with reference to the bill published on the website of legal information regulation.gov.ru reported.

The Ministry of Health decided to legalize telemedicine in Russia
The Ministry of Health decided to legalize telemedicine in Russia

In the bill it is noted that services of telemedicine can include only remote prevention, diagnostics or observation of the state of health of the patient, but not treatment.

The initiative of the Ministry of Health also provides exchange of medical documents in electronic form, but only between doctors at their obligatory identification and patients and also on condition of nondisclosure of personal data.

The Ministry of Health was engaged in development of the bill of legalization of telemedicine in Russia with the assistance of the Adviser to the President on the Internet of German Klimenko and the special working group into which enter including representatives of the Internet Initiatives Development Fund (IIDF). According to Klimenko, this working group is going to provide the version of the bill which, in particular, assumes the accelerated beginning of regulation of telemedicine in the Russian Federation.

According to the board member of network of clinics "The Doctor Is Near" Vladimir Gurdus, the Russian market of telemedicine is developed very poorly and has small volume, and the bill will help it to grow several times by 2021-2023.

The managing director Alexander Ledovsky of network of clinics "Ramsay Diagnostics" considers the bill insufficiently detailed, but capable to bring telemedicine out of semi-legal provision.

At the same time remote consultation will not be able to replace completely internal survey and functional diagnostics, telemedicine is an option of medical care as a last resort if the patient cannot personally come to the doctor, the senior vice president of network of Medsi clinics Igor Krylov notes.[9]

"Yandex" and the Ministry of Health prepare the bill of telemedicine

On March 4, 2016 it became known that Internet Yandex Company and the Ministry of Health of the Russian Federation will be engaged in development of the bill of telemedicine. Thanks to it the Russian patients will be able to get remote advice and treatment.

According to Kommersant with reference to the CEO of "Yandex" in Russia Alexander Shulgin, in March, 2016 the company together with the Ministry of Health will create the working group for preparation of the bill of telemedicine which will create the legal basis of use of IT in health care. The Ministry of Health placed the notification on the beginning of development of the relevant bill on the federal portal of projects of regulatory legal acts.

\"Yandex\" and the Ministry of Health begin to develop telemedicine in Russia
"Yandex" and the Ministry of Health begin to develop telemedicine in Russia
«
We consider important development and the approval of the uniform standard of storage and the data exchange protocol about health. This important condition for development of telemedicine in Russia — Alexander Shulgin said.
»

According to him, the main directions in this area are access for the patient to electronic data of the medical record, settlement of identification of the patient and doctor when rendering telemedicine services and also an opportunity in electronic form to provide consent to access and data processing on health.

Within information technology development in the Russian medicine the Ministry of Health is also going to enter invoicing of sick leave notes and recipes in electronic form since July 1, 2016. The exception will be made for narcotic and psychotropic substances, reports the edition, referring to the bill published by the Ministry of Health.

The co-founder of The Doctor at Work company Stanislav Sazhin says that invoicing of electronic recipes in Moscow began in 2014. However such service is limited and extends only to medicines for preferential categories of the population — according to such recipe of medicine are free therefore patients require it to issue, Sazhin noted.[10]

Notes