Внедрение электронного здравоохранения в маленькие города - г. Звенигород.

Contents
Introduction
Part 1. The current state and problems of Public Health Service system in Russia
Part 2. The level of e-Public Health Service in Russia
Part 3. The role of e-Public Health Service in solving the Public Health Service problems in Russia
Part 4. E-Public Health Service in Zvenigorod: the assessment of current state and problems of development
Part 5. Perspectives of implementation of e-Public Health Service in Russia: economic analysis
Conclusions
List of references

The addition of technology should not substitute for failed pedagogical process, but technology should allow that educational process, and the message to be disseminated, and tailored to individual groups and professionals, by retaining along some of the educational principles of traditional education. E-Health education centres on these principal issues:
Distance learning;
Continuous Medical Education (CME) for medical professionals;
Advanced e-Health professionals education in the changing environment;
Patient’s education in health related issues in the information age.
While distance learning benefits are not challenged by most, it is difficult to estimate the impact on education overall. Nonetheless, is becoming more and more prevalent around the world. In a survey of Internet found more than 3,000 programs and 1,100 accredited institutions using distance learning in 1,400 fields of studies, represented by over 50,000 courses.
The impact of distance learning should be measured by the content of the curriculum which should be based on the process, perception, product and the mode of delivery. As such distance learning and distance education process should be scrutinized just as traditional curriculum has been in the past and continue to be so. The only “change” should really be the medium of dissemination. Not the content per se, not the overall approach, and certainly not the end product, which is the education of the students, health professional and, the patients them self. The differences between classical teaching and learning, and new and modern form of teaching as well as learning is substantial in this new era. Instead of confined classroom teaching and learning, the entire universe has become a workplace, a learning environment, anywhere, anytime, 24 hours a day. This creates a sense of shared knowledge and virtual networking alliances.
The demand for distance learning stems from the common sense of its applicability, but it requires the same standards of production, and evaluation of such programs.
The main reasons to implement distance learning in health education are:
Healthcare professional, in the information age, will acquire new skills and new knowledge without major disruption of their work.
The need to reduce the cost of obtaining such education on new information (travel expenses, lodging, registration fees on venues like clinical conferences, congresses, and other forms of meetings).
Need for better convergence of information age healthcare professional in communication and computing technologies.
Continuous Medical Education is an important aspect of healthcare professionals in order for them to maintain the acquired knowledge, and to gain new information, which will make possible:
To offer the best possible care to their patients implementing current standards of care.
To satisfy governmental, institutional and scientific and clinical societies requirements for licensing, membership, and good standing in societies, associations and other organized forms of healthcare professionals.
To ensure that, they are up to speed with current medical practices.
Distance learning and advances in technologies allows healthcare professionals to participate in CME programs without disrupting their daily routine work to participate in the traditional meetings. Furthermore, it allows and ensures consistency throughout the educational process among peers, institutions and countries.
The question how technology will change our world is not anymore relevant. The answer to this question is obvious. The advances in e-Health education have brought significant changes in health education overall. Advanced technologies such as computers, diagnostic imaging, robotics, voice-activating machines, and remote controls have changed hospitals and operating theatres in hospitals around the western world. In parallel with these developments, the patient has become an educated and informed consumer who:
Questions the decisions of the practitioner and demand explanations and an evidence based medicine approach.
Validates his or her expertise through web sites and other forms.
Requires that the doctor offers care, current with world standards.
Furthermore, today’s patient can consult any expert in the field, in any country of the world, at any time without respect to geography and distance. At the same time, the world equilibrium has not followed the punctuation of the industrial world directed by the broad bandwidth rush, and there is a huge discrepancy between countries and continents. Subsequently, there is a great need for e-Health education to become a catalyst of equilibration among countries and nations as we move toward a perfect future and electronic globalization. The wide application of e-Health education programs, will most likely narrow significantly, if not eliminate entirely, the gap between the countries delivery health systems, and between the imagination, dreams, and achievements of those who do not have the capability to apply new healthcare standards, and those who have such capabilities. For these radical changes to become a reality it will take time and investment, as well serious international collaboration, but the concept of e-Health education has the potential to offer such radical changes, and for the most part, has been accepted, adopted around the world, and has raised hopes that it will create equality and equilibrium in the education of patients and healthcare professionals.
Education of health providers is a major issue in the current environment, as there is a great need for advancing the education process of all healthcare professionals. The report of the Institute of Medicine in 2001 states that clinical education simply has not kept pace with or has been responsive enough to shifting patient demographics and desires, changing health system expectations, evolving practice requirements and staffing arrangements, new information, focus on improving quality and new technologies. As such, healthcare providers have not been prepared adequately in either academic or continuing education venues to address these major changes in patient population. Patients around the world are becoming better educated, are living longer and aging significantly, and are increasingly inflicted by one or more chronic illnesses. Only in the United States of America, 40% of its population or 125 million people live with some type of chronic condition, and about half of them live with multiple such conditions. Subsequently, they are more likely to seek more health information which challenges significantly the landscape of clinicians and their practices. Healthcare providers are more and more asked to work on inter-disciplinary teams, often supporting patients with chronic conditions, although they may lack the training and education that is based on a team-based approach. Based on multiple reports and analysis, the twenty first century healthcare provider, and system, should ensure that all healthcare professionals be educated to deliver patient-centred care as members of an inter-disciplinary team, emphasizing evidence-based practice, quality proven approaches and informatics. This approach should ensure the establishment of basic fundamentals of health professionals’ education regardless of their discipline, in order to meet the needs of the twenty-first century health advances and care. The report by the Institute of Medicine of the National Academies, states that many organizations, experts, health professionals, and increasingly the public, question whether quality healthcare can be delivered under the existing healthcare systems, noting that healthcare today harms way too frequently, and consistently fails to deliver its potential benefits. These errors as documented by the authors of “To Err is Human: Building a Safer Health System” results in tens of thousands of American dying each year and hundreds of thousands suffering or being sick. Issues like these and the need for globalization of standards and creations of standards in the healthcare arena make e-Health education a very attractive avenue for providing such a medium where geography and distance become truly abstract nouns.
The presented information on theoretical aspects of e-Health and practical results in European countries should be used for Russian regions as well. Telemedicine and e-Health are just becoming priority theme for authorities in Russia. Experts start to understand that opportunities and positive potentials of IT implementation in medicine and public health system as well could create a basis for solving problems in the country. As it was mentioned in part 1 and part 2 of this survey, Russian public health system is not in such a good shape, it requires serious steps for reforming. The most important cases are small cities and rural areas where all the spheres of life are lower if comparing the level of central regions (capital, big cities and regions with high revenues).
The perspectives of e-Health in Russia and Russian regions could be seen on the results of pilot projects that will start this year (2010) in Nizhnekamsk region (Tatarstan Republic). The same projects will be in Astrakhan city and Bashkortostan. This project provides the informatization of medical institutions, they will be covered with PC network with unified information system. Tatarstan vise prime minister N. Nikiforov said: “Every doctor and nursery in the region will get a personnel computer. As a result will appear the possibility to administrate working hours of medical personnel more constructively, as well as resources of medical equipment (e.g. tomographic scanner, roentgen and other deficit equipment). However there is a difficult part of the project – small budget that amounts to 25 million rubles.
The described project provides the integrated system of electronic hospitals, health centers and rural medical departments in connection with system of compulsory medical insurance. The information about medical insurance policy of every region citizen should be in a special universal e-card. According to the authorities plans this year will be enacted a law on e-services in Russia that could be a legal basis for l e-cards. E-card in general is an instrument for authorization of every citizen in e-government system, it helps to sign e-documents.
Russian authorities are planning to become use e-cards in real life starting from November 2010.
Russia is going to use the European experience in this field, because in such countries as Germany, Netherlands and France e-Health system (including in the rural areas) demonstrated a positive progress in widespreading medical services among the population. The main advantages are reducing costs and increasing services quality. That’s why telemedicine and e-Health could be interested for Russian regions, especially in rural areas where people do not have adequate access to high quality medical services.
In a number of the European medical institutions it was developed the system of medical monitoring and association of systems of an archiving, storage and processing of images with clinical information system which includes system of a call of the nurse with possibility of direct dialogue, system of monitoring of a condition of the patient, tracing of patients movings and equipment, video-consultation and telemedicine.
The decision offered by company “Cisco” allows to communicate between the various devices transferring and receiving vocal or text messages, between users of stationary devices and mobile users (the doctor on duty, the nurse, traumatologic branch, managers of a network, etc.). The system processes the signals arriving from the medical equipment, connected to the patient for monitoring of its condition, the button of an urgent call at the patient, the first aid button in special rooms (toilet rooms, in accident wards, procedural, etc.) for a call of the urgent help, signals from technical supervising systems. The call of the nurse is carried out with possibility of direct dialogue with her/him.
The system of medical monitoring allows to make tracing of movings of patients, the medical personnel and the equipment. The patient and units of the medical equipment (an invalid armchair, droppers, etc.) are supplied with special labels. As a result of constant interaction of these labels and wireless points of access the system always knows a site of each unit of equipment and the patient or medical staff. From any accessible computer the program with the image of a card of the medical centre, and means of search which can be made under the name, to type or equipment number is caused, the site which is highlighted on a card is defined. If labels supply also patients and nurses, there is a possibility to define who and during what time used a concrete unit of equipment. If attempt of export of the equipment will happen or in a case when the patient leaves certain territory, protection can be warned in advance about it.
It is not a time to talk about the existence of such system in Russia in the short-term perspective because of serious problems of Russian public health system.
One of the main barrier in Russia is a low level on informatization of the country. It is becoming a big problem for Russian regions where we can see not only the lack of Internet-access, but a lack of PCs. Small financing of medical system not allow to medical institutions to use the money for every need, the priority now is a medical equipment for patients treatment and different medicines.
For an effective work of telemedicine with a use of mentioned e-cards it is needed to create National telemedicine System where it will be possible to get the information about all patients and to reach the network of professional doctors.
Another aspect that is an important for Russian specifics is a low level of population trust on medical services quality. For example, 70% of population in Russia do not trust to public health system, the same percentage of Europeans believe to their national medicine.
Next part of the present survey will be devoted to small cities and rural areas, because they have their own specifics that are came from their location and small percentage of persons per squire km (not every small city or village has its own medical department or even a hospital).

Part 4. E-Public Health Service in Zvenigorod: the assessment of current state and problems of development
The city Zvenigorod is located in the west of Moscow Region in 50 km from Moscow between transportation highways of the international value – the Minsk and Riga highway.
City territory – 4746 hectares.
The city Zvenigorod is one of the most ancient in North-East Russia, presumably based by Jury Dolgorukim in 1152, for the first time it is mentioned in the spiritual reading and writing of Moscow prince Ivan Danilovicha Kality in 1339, since the same time it becomes the centre of a specific princedom.
The budget of Zvenigorod in 2008 was 1 062 million rubles that is higher than in 2003 in 13,5 times (the budget of 2003 – 78,6 million rubles).
The national project “Health”. In Zvenigorod since 2004 the program “Prevention and struggle against diseases of social character» is realised. Construction of the Central city hospital of Zvenigorod is conducted. The medical center (or polyclinic) is built, it is operating with 600 visitors per day, it is also equipped by the modern medical facilities. The reconstruction of city hospital of Chekhov was made.
In 2009 the Zvenigorod population according to preliminary data has increased by 277 persons and has made for January, 1st of 12990 persons.
The general increase in number has occurred at the expense of migratory processes. For 12 months of 2009 natural decline in population has made 313 persons that 28,5% less than the corresponding period of last year (438 foreheads).
Pic. 3.
Comparing the birth rate of the accounting period with the corresponding period of last year it is necessary to note the increase in birth rate at 16,9%; the quantity of the died has decreased on 17,2%.
Pic 4. Results of natural population movement in Zvenigorod, 2008-2009
Death rate principal causes were illnesses of system of blood circulation, a trauma and a poisoning; to a lesser degree – illnesses of respiratory organs, new growths. Cases of infantile death rate are not present.
Pic. 5. Mortality of Zvenigorod population, 2008-2009, persons
Population decrease constrains positive balance of migration. In comparison with the corresponding period of last year its considerable increase (2008 – 222 foreheads, 2009 – 572 persons) is marked.
Pic. 6. Results of population migration, 2008-2009
Age structure of Zvenigorod population is the following: 14% - children till 15 years, 59% - citizens of able-bodied age, the others of 27% - citizens are more senior able-bodied age.
At comparison of distribution of the population on age with last year it is necessary to notice that at the general decrease in a population relative density of citizens of different age groups to a population aggregate number remained without changes.
Pic. 7. Zvenigorod population age, Janary, 1st, 2009
The greatest relative density in a population aggregate number is occupied with women – 58,2%; in comparison with the corresponding period of their last year became more on 1%. In a category of the children's population and citizens of able-bodied age the parity of men and women almost ideally, and in a category of citizens is more senior able-bodied age number of women makes 73%.
Pic. 8. Number of population on sex, January, 1st, 2009
In a category of citizens the greatest relative density is younger than able-bodied age - 34,1% are occupied with children from 0 till 4 years. In comparison with last year increase at 1,7%. In a category of citizens of able-bodied age the greatest relative density – 13,7% and 14,0% is occupied with aged people accordingly 45-49 years and 20-24 years. At comparison of this indicator with 2008 growth on 2,7% only at the age of 20-24 years is marked. In a category of citizens the greatest is more senior able-bodied age specific – 45,2% are occupied with people of 70 years and is more senior that on 0,1% less than last year.
For 12 months 2009 Registry Office has been registered: marriages–348 (on 15 marriages less than the corresponding period of last year), divorces – 126 (in the corresponding period of last year of divorce cases too 126).
If to consider dynamics of marriages August of current year became most "fruitful" by quantity of the concluded marriages – 53 marriages. In August, 2008 it has been concluded 81 marriages.
Pic. 9. Dynamic of marriages and divorces, 2009
Summarizing the mentioned information, it is possible to say that Zvenigorod city is a typical example of a small city in Russia, that’s why we can assess the perspectives of e-health system on it. The analysis is made on the bases of questionnaire among medical personnel of Zvenigorod city and close rural areas (countries).
100 persons working in medical sphere were polled. Their structure is showed in Pic. 10 and 11.
Pic. 10. Structure of respondents, came from
Pic. 11. Structure of respondents, years old
The close location to Moscow (50 km) determine the high percentage of medical personnel with university diploma – more than 75%. 25% graduated form colleges.
93% of respondents have heard about e-health system and have the basic knowledges about plans on implementation it in Russia.
The following sources of information about e-health and telemedecine interviewers have used:
medical university – 58%;
training programs – 40%;
conferences/seminars – 39%;
medical journals – 20%;
Media (television, newspapers, etc.) – 42%;
colleagues – 51%.
Zvenigorod medical personnel consider that the use of e-Health in their work could be effective.
The main idea that IT technologies could help patients from rural areas to get medical aid distantly doesn’t work in Russian Federation, including Zvenigorod city and its suburbs, because of low penetration of Internet and computers. The main source of connection for present days – telephone line and mobiles (mobile lines start to be adequate in Russian regions just during last years). The other problem is low level of IT education among medical personnel and population in general in regions – most of medical personnel taken part in questionnaire think that they need a special education programs to learn the basics of IT use. So, they would like that their working place and infrastructure will be simple in use. Such kind of statistics influences badly on perception of e-Health in small cities – 60% of respondents replying the question “Use of e-Health – is a bad idea” said they are not completely agree or disagree. Just 30% supported telemedicine as a good perspective in future.
Respondents agree that e-Health will help to make more correct diagnosis and treatment, because doctors will get a network with other qualified specialists form Russia and even form other countries.
Medical personnel of Zvenigorod consider that the systems of e-Health should have reliable protection (privacy and confidentiality) of medical information about patients.
Nowadays use of IT systems is perceived as “additional job”, because Russian medical personnel have a rule to work with “old methods” and just after their work to осваивать new programs.
Medical experts think that the role of authorities is a key, they wait for their information, technical, educational and financial support.
Medical personnel of Zvenigorod city and rural areas support the general idea of e-Health, they understand the whole spectrum of advantages that are learnt already in European counties and showed high results. But in the same time Russia has its own specifics that are seen especially in small cities – insufficient level of information technologies penetration and a lack of education among medical personnel. The general problem for Russia is a low level of financing public health system, it resulted a big percentages of dissatisfied population in level of medical services.
Part 5. Perspectives of implementation of e-Public Health Service in Russia: economic analysis
Expectations for the positive role of telemedicine in healthcare reform rest on its unique attributes and, more specifically, the manner in which it addresses each of the following problems in healthcare delivery:
The prevailing inequities in access to care that reflect geographic, socioeconomic, and cultural disparities.
The inefficiencies and limited coordination and integration of complex systems of healthcare.
The uneven distribution of quality of care, uneven adherence to evidence-based medicine, high prevalence of medical errors, and the wide adoption of unhealthy lifestyles.
The technology of telemedicine consists of electronic tools for the acquisition, processing, dissemination, storage, retrieval, and exchange of information aimed at promoting health and preventing disease, treating the sick, rehabilitating the disabled, alleviating pain and suffering, and protecting the public’s health and safety. The traditional boundaries between telemedicine, telehealth, and e-Health have become blurred, partly as a result of a general liberalizing trend in modern society that normally starts with the nomenclature before it becomes manifest in actual practice and partly because of the overlapping functions between medicine and public health and their convergence on using the same technology in this instance.
Over the last decade or so, the changes led by the digital revolution have created a wave of new technologies that now pervade industrialized societies as well as less developed ones. In turn, these technologies have created pressures for changes in healthcare. For instance, the Internet has spawned a wealth of health information at the fingertips of providers, consumers, lay support groups, and special interests. It has also opened vastly expanded opportunities for increased access to information and sources of care that transcend the barriers of time and place.
Despite their immense promise, the diffusion of programs that rely on ICT in healthcare delivery has been selective and slow. Whereas large medical centers now rely on ICT in routine operations, such as billing, scheduling, and communications, there has been a general reluctance to broaden their applications to incorporate remote consultations with colleagues located in other places, in-home monitoring of chronically ill patients, triaging patients and coordinating their care throughout the system, remote mentoring of colleagues in complex surgical procedures, streamlining the clinical process between diagnostic and clinical services, and integrating multisite delivery systems. All of these are core functions in telemedicine.
Most medical centers are currently facing a perilous financial situation from declining revenues. Some have found it expedient to reduce their investment in ICT. Moreover, the prospect of providing additional services via telemedicine is not inherently attractive to them because of significant limitations and restrictions on reimbursement for these services. As supported by scientific evidence, a fair reimbursement policy would equate services delivered electronically to those delivered in person.
During the last two decades, the federal government has assumed the dual role of supporting telemedicine projects and also placing obstacles to the orderly deployment of sustainable programs. Several federal agencies have provided substantial grant funding for project start-ups and research in this field. At the same time, some federal programs have adopted the use of telemedicine in their operations.
In the current economic environment, it would be futile to propose solutions in healthcare that simply add expenditures without having a clear and explicit expectation of significant returns on investment. Indeed, it would also be simplistic to assume that a single fix such as a massive infusion of funds for building the IT infrastructure in healthcare alone would result in a vastly improved health system that is affordable and accessible.
Perspectives of implementation of e-Health and telemedicine in Russia will become positive after three main activities:
Firstly, increasing the financing and budgeting the public health system in the country. In developed western states such budget reaches 16% of GDP (in United States). In Russia this percentage is on the level 3-5% (according to the UN statistics).
Secondly, developing the educational level of medical personnel through the elaborating the IT programs in universities and colleges.
Thirdly, developing the National Telemedicine System. This year are planning just first pilot projects in three Russian regions.

Conclusions

The explosive developments in information and communication technologies (ICT) in the last decade allow for new kinds of healthcare scenarios. In the light of future demographic and economical developments, the current concepts of healthcare provision will have to move more and more from patient care and disease management towards prophylactic services for healthy citizens. The concept of health insurance, which currently mainly guarantees the treatment of illness and diseases, will increasingly have to focus on programmes to stay healthy. Consequently, a new type of industry (besides the already existing pharmaceutical industry and the industry for medical imaging devices, currently being the two largest industrial sectors in healthcare) will evolve in the healthcare domain that will serve the market with eHealth and Telemedicine products and services for improved diagnosis and therapy for patients, but will increasingly expand its product variety into the domain of health preservation for the general citizens.
In their current strategic planning for the next years, healthcare authorities at a European level have already set concrete deadlines up to the year 2008 for a range of concerted measures for improved healthcare by implementation of various ICT-based concepts. These include:
Roadmaps for wide implementation of eHealth and Telemedicine systems and services
(including reimbursement and liability issues)
Deployment of health information networks using broadband infrastructures and GRID technologies;
Promotion of open standards and open source solutions, interoperability of Electronic Health Records; introduction of Europe-wide patient identifiers;
Promotion and adoption of the use of the electronic health insurance card;
Provision of accredited online continuous education and training in eHealth for health professionals;
Deployment of a European Public Health portal providing dedicated information to citizens for health education, safety at work and disease prevention;
Introduction of legal, ethical and regulatory measures for eHealth and Telemedicine services such as standardised European qualification, increased certainty and liability also with respect to the increased mobility of citizens;
Support and boosting of investments in eHealth and Telemedicine, support research and development in the combination of technological and organisational nnovations, facilitating synergies between European programmes and national policies;
Dissemination of best practice by international collaborations.
Inefficiency is currently a major burden in healthcare provision. The wide deployment of eHealth and Telemedicine services will influence the current workflow in many situations. Also the establishment and implementation of evidence-based medicine will allow for a number of improvements in the field of disease prevention, diagnosis and therapy. Increasingly it will become possible (e.g. through advanced body checks) to diagnose certain diseases even before any symptoms have become manifest. These new possibilities require a re-evaluation of the medical workflow and decision-making tree. Process management and change management studies are needed to identify and implement a newly optimised workflow to allow for a smooth, effective and efficient implementation of new processes and services. Implementation of multi-focal management strategies will allow for flexible and tailored management approaches.
E-health and Telemedicine will increasingly involve the temporary formation of global virtual enter-organizational alliances, centring upon human cooperation and flows of information. Such partnerships rely on trust, which often needs to evolve swiftly due to tight deadlines.
When trust prevails, partners are more confident in being open with each other, knowing that information and ideas shared will be used for the benefit and advancement of the partnership. Improved management in global virtual alliances requires the implementation of new tools and strategies for developing and sustaining trust in the diverse and global digital human community, for building virtual communities among patients at global level, for developing virtual communities among medical experts to enable continuous teletraining for stablished medical experts as well as to support medical teleeducation in developing countries.
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Annex. Questionnaire of medical personnel
Развитие медицинских кадров: обзор Документационного центра ВОЗ // Информационный бюллетень для руководителей здравоохранения. 2006. Выпуск 16. С. 1.
Всемирный день здоровья 2006 года. Практическое руководство по информационно-разъяснительной работе // URL: http://www.mednet.ru/whodc/rus/TOOLKIT_RU_150306final.doc
Ibidem.
Развитие медицинских кадров: обзор Документационного центра ВОЗ // Информационный бюллетень для руководителей здравоохранения. 2006. Выпуск 16. С. 1.
Всемирный день здоровья 2006 года. Практическое руководство по информационно-разъяснительной работе // URL: http://www.mednet.ru/whodc/rus/TOOLKIT_RU_150306final.doc
Всемирный день здоровья 2006 года. Практическое руководство по информационно-разъяснительной работе // URL: http://www.mednet.ru/whodc/rus/TOOLKIT_RU_150306final.doc
Там же.
Всемирный день здоровья 2006 года. Практическое руководство по информационно-разъяснительной работе // URL: http://www.mednet.ru/whodc/rus/TOOLKIT_RU_150306final.doc
Там же.
Приказ Министерства здравоохранения и социального развития Российской Федерации от 5 февраля 2008 г. №48 «О Комиссии Министерства здравоохранения и социального развития Российской Федерации по разработке концепции развития здравоохранения до 2020 года» // URL: http://www.minzdravsoc.ru/docs/mzsr/orders/585
Концепция развития здравоохранения до 2020 года. Экспертная площадка открытого обсуждения Концепции развития здравоохранения до 2020 года // URL: http://www.zdravo2020.ru/conception/5
Тогунов И.А. Проблемы интеллектуального и кадрового менеджмента здравоохранения // URL: http://www.rusmedserv.com/zdrav/menegzdrav/article_86.html
Ibidem.
Ibidem.
Ibidem.
2