Evaluation of operation efficiency of all-ukrainian telemedical network of transtelephone electrocardiography «Telecard» in 2005-2006
06/12/2007
During 2004-2005 the Ministry of Health of Ukraine bought within the scope of the program of development of rural medicine 50 transmitting devices and 57 central receiving stations of the set of transtelephone ECG «Telecard». Totally 52 Remote diagnostic centers (RDC) have been created. In a number of regions the number of receiving stations installed in one institution have been doubled on the request of the heads of Health Care Administration. At the first stage (delivery in 2005) the RDCs were created in regional centers (total 25). The transmitting devices were installed in 270 Central Regional Hospitals (CRH) of the corresponding regions.
At the second stage (delivery in 2006) the RDCs were created in CRHs of the majority of regions of Ukraine, as well as in the system of the Emergency Call service (total 26). Three hundred transmitting devices have been installed in rural and family outpatient departments, as well as in ambulance cars. Besides, in 2006, thanks to sponsor assistance and own means of Dolinskaya CRH of Ivano-Frankivsk region, a set of equipment was purchased, consisting of one receiving station and seven transmitting devices «Telecard».
Thus, for the first time in the post-soviet countries an integral actually working telemedical system has been created, oriented at providing an urgent diagnostic aid first of all to inhabitants of rural and remote regions.
This fact is even more surprising, because before the «Telecard» network has been created in Ukraine, the development of telemedicine in Ukraine dwelt so to say virtually, confined to the limits of reports at conferences and timid attempts to transmit some medical information basing on standard telecommunication technologies. By the way, in contrast to the Russian Federation, where the Interagency Committee «Russian Telemedicine» was created by order No.207 from December 21, 2000, and the Concept of development of telemedical technologies in the Russian Federation and the plan of its realization was approved by the order of the Ministry of Health of the RF No. 344/76 from August 27, 2001, and the Coordination council of the Ministry of Health of the Russian Federation in telemedicine, headed by the Deputy Minister, was created, which included the leading specialists from various medical institutions of Russia, who earlier implemented telemedicine into the actual clinical practice at their own fear and risk.
Almost simultaneously with the official acknowledgment of the importance of telemedicine, nongovernmental institutions have appeared in Russia, aimed at the promotion of telemedical technologies and creation of corresponding organizational structures. In particular, on the basis of the Central Institute of traumatology and orthopedy and A.V.Vishnevsky Scientific and Research Institute of cardiovascular surgery, the Federal fund «Telemedicine» has been created. With the assistance of Bakulev S&R Institute of cardiovascular surgery the Russian association of telemedicine has been created, which eagerly started to create a united actually working telemedical network in Russia.
It is hard to convey the amazement of the Russian specialists in telemedicine, when they found out that the All-Ukrainian telemedical network «Telecard» has been created, and they got acquainted with the first results of its operation. It is even more amazing that this system has been created without the intellectual support from any governmental structures or public Ukrainian organizations, actually on bare enthusiasm of the manufacturing company and by the arbitrary decision of the heads of the Ukrainian Ministry of Health. However, the Ministry of Health had sound reasons for starting purchasing the «Telecard» system, as to that time at the expense of local budgets the regional remote diagnostic centers (RDC) have been created in Kharkov, Kherson and Sumy regions, and there was a substantial positive experience of equipment operation.
Till September 2006, an experience was accumulated in delivering transtelephone cardiological consultations, sufficient to draw up initial conclusions. All data given below on the number of recorded ECGs are as to September 1, 2006. Thus, the RDCs created on the level of regional centers, received ECGs during 2005 and eight months of 2006. The Central regional hospitals received ECGs during 2006, except CCH in towns of Belaya Tserkov and Krasnograd, where the equipment was installed according to the quota of the Ministry of Health only in August 2006.
Summary information on the total number of electrocardiograms recorded by regional RDCs is given in Table 1, and by district RDCs in Table 2. In total 12345 ECGs were transmitted over the specified period of time, and not a single complaint from the users on the quality of recorded ECG was registered. It is expedient to carry out further analysis in the form of «Regional RDC – districts» and «District RDC – ambulance stations».
It follows from the analysis of Table 1 that the efficiency of «Telecard» complex operation substantially differs throughout the country. Depending on the number of recorded ECGs, regions can be selected, which operate equipment most and least effectively.
1. Regions that use «Telecard» most effectively: Vinnitzkaya, Chernigovskaya, Kherskonskaya, Poltavskaya, Donetskaya, Kirovogradskaya, Ternopolskaya and Kharkovskaya (see Fig. 1).
Fig.1. Regions that use «Telecard» effectively
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Table 1.
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Table 2.
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No.
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Name
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No. of ECG
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No.
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Name
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No. of ECG
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1
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Vinnitskaya Regional Clinical Hospital (RCH)
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1850
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1
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CRH Dolina, Ivano-Frankovskaya region
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687
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2
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Chernigovsky Regional Cardiological Dispensary (RCD)
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1330
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2
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CTMA Kovel, Volynskaya region
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445
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3
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Khersonsky RCD
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1220
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3
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CRH Kozyatin, Vinnitskaya region
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350
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4
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Poltavsky Regional Clinical Cardiological Dispensary (RCCD)
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1146
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4
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RCH Stryj, Lvovskaya region
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301
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5
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Donetskoe Territorial Medical Association (TMA)
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1100
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5
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CRH Storozhynets, Chernigovskaya region
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238
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6
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Kirovogradsky RCD
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646
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6
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TMA Mogilev-Podolsky, Vinnitskaya region
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159
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7
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Ternopolskaya RCCH
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489
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7
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CRH Znamenka, Kirovogrdskaya region
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131
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8
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Kharkovskaya RCH
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485
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8
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CRH Krolevets, Sumskaya region
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129
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9
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Symskoy RCD
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364
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9
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CRH Sarny, Rovenskaya region
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72
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10
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Zhitomir RMCDC
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138
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10
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CRH Genichesk, Khersonskaya region
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70
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11
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Nikolayevskaya RCH
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127
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11
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CRH Mikhailovskoe, Zaporozhskaya region
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61
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12
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Lvovsky RCD |
101
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12
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CRH Berdichev, Zhitomirskaya region
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60
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13
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Khmelnitsky RCD
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97
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13
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CRH Kamenets-Podolsky, Khmelnitsky region
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55
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14
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Cherkassky RCD
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97
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14
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CRH Voznesensk, Nikolayevskaya region
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37
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15
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Luganskaya RCH
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86
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15
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Emergency Uman, Cherkasskaya region
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30
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16
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Rovenskaya RCH
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64
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16
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CRH Pokrovskoye, Dnepropetrovskaya region
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30
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17
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Ivano-Frankovskiy RCD
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30
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17
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CRH Balakleya, Kharkov region
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28
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18
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Zaporozhsky RCD
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25
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18
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CRH Lubny, Poltavskaya region
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27
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19
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Zakarpatsky RCD
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18
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19
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CRH Krivoj Rog, Dnepropetrovskaya region
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24
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20
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Odesskaya RCH
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12
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20
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CRH Belaya Tserkov, Kievskaya region
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20
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21
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Dnepropetrovsky RDC
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9
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21
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CRH Skole, Lvovskaya region
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15
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22
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Krymsky RCD
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0
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22
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Emergency Cherkassy
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12
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23
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Kievsky RCD
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0
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23
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CRH Tyachevo, Zakarpatskaya region
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8
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24
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Lutskaya CCH
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0
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24
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Emergency Simferopol, AR Crimea
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8
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25
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Chernovitsky RCD
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0
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25
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CRH Krasnograd. Kharkovslaya region
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2
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TOTAL
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9434
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26
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Emergency Yalta, AR Crimea
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2
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27
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CRH Amvrosievka, Donetskaya region
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0
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TOTAL
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3001
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2. Regions, which virtually do not user «Telecard» in their work: Chernovitskaya, Volynskaya, Kievskaya, Dnepropetrovskaya, Odesskaya, Zakarpatskaya, Zaporozhskaya, Ivano-Frankovskaya and AR of Crimea (see Fig.2).
3. The best nine regional RDC together have registered 91 per cent of total number of ECGs, the worst ones – 1 per cent.
4. If the maximum at this stage efficiency of operation of the complex for transmitting ECG over a phone, demonstrated by Vinnitskaya RCH, was reached, the total number of ECG registered in entire Ukraine at the «Regional RDC – Districts» would reach 46250 over incomplete two years. Thus, present received 9434 EXG are only 20 per cent from really attainable efficiency of the whole telemedical network. Missing ECGs, 36816, is a 80 per cent reserve for increasing the efficiency of operation of telemedical network «Telecard».
3. The best nine regional RDC together have registered 91 per cent of total number of ECGs, the worst ones – 1 per cent.
4. If the maximum at this stage efficiency of operation of the complex for transmitting ECG over a phone, demonstrated by Vinnitskaya RCH, was reached, the total number of ECG registered in entire Ukraine at the «Regional RDC – Districts» would reach 46250 over incomplete two years. Thus, present received 9434 EXG are only 20 per cent from really attainable efficiency of the whole telemedical network. Missing ECGs, 36816, is a 80 per cent reserve for increasing the efficiency of operation of telemedical network «Telecard».
Fig.2. Regions, which actually do not use «Telecard».
According to the estimates of the specialists from Poltavsky regional clinical cardiological dispensary, 33.6 per cent of transmitted ECGs are cases of acute myocardial infarction, 56.3 are complex cases of rhythm and conductivity disturbances, 10.1 per cent are simpler cardiological pathologies. Using these electrocardiograms when discussing situations with the CRH doctors, the RDC specialists of Poltavsky RCCD discuss a possible tactics of patient treatment, perform differential diagnosis of changes on the ECG, solve problems of calling a cardiological brigade of the department of urgent cardiology.
Thus, these 36816 ECGs not obtained – it is the consultive aid, not given timely to 12370 patients with acute myocardial infarction and 20727 patients with complex disturbances of rhythm and conductivity. The LLC «TREDEX Company» has no statistical data as to to what part of these patients the absence of highly qualified diagnostic aid turned out to be lethal.
The analysis of Table 2 makes it possible to conclude on the efficiency of «Telecard» complex utilization at level «District RDC – ambulance stations». One must name among the leaders CRH Dolina of Ivano-Frankovskaya region, ITMA Kovel, Volynskaya region, CRH Kozyatin Vinnitskaya region, CRH Stryj, Lvovskaya region, CRH Storozhynets, Chernovitskaya region, TMA Mogilev-Podolsky, Vinnitskaya region, CRH Znamenka, Kirovograndskaya region, CRH Krolevets, Symskaya region (see Fig. 3).
Fig.3. Regions, which CRH successfully use «Telecard».
So, RDC of Kovelskaya CRH during five months of 2006 have received already 445 ECGs of the patients living in rural areas of the district. Stryjskaya CRB (Lvovskaya region) for the same period received more that 300, RDC of Dolinskaya CRH during a part of 2005 and 2006 – 687 ECGs. If we take into account that none of the villages where the «Telecard» transmitters are installed was ever visited and will never be visited in foreseeable future by a good cardiologist, and the course and outcome of cardiological diseases are often counted by minutes from a seizure onset till the beginning of correct treatment, we can hardly overestimate the significance of a transtelephone electrocardiograph.
It follows from the comparison of Figures 1-3 that Vinnitskaya, Kirovogradskaya and Sumskaya regions are in the group of leaders both at the regional and district levels of organization of the telemedical network operation.
But of significantly greater interest is the fact that the CRH Dolinа, MTMA Kovel and CRH Storozhynets are absolute leaders as to the efficiency of «Telecard» complex operation in the scope of the whole country, while Ivano-Frankovskaya, Volynskaya and Chernovitskaya regions, respectively, are the leaders of antirating at the level «Regional RDC – districts».
It seems impossible at present to select the least successive districts, as the information on their efficiency is greatly determined by the fact that a number of districts started actual operation of the equipment in summer or obtained the «Telecard» complex only in August 2006. Conclusions made over such short period of time can be premature.
Of significant practical importance is to look for reasons of such different efficiency of operation of one and the same equipment under practically identical operating conditions.
The geographical principle must be excluded, as both leaders and outsiders represent virtually all regions of Ukraine.
Similarly, claims to the equipment seem inappropriate, because all regions and districts use one and the same equipment, demonstrating antipodal results.
Differences in the level of equipping regional rural medicine with high-quality electrocardiographs and in the level of staffing the regional cardiological centers, CRH and ambulatory stations with qualified medical and paramedical personnel seem insignificant. As a whole, in the scale of the whole country the insignificant differences cannot lead to antipodal results.
In the course of operation of the equipment the medical personnel work with telephone lines of approximately the same, far from good, quality.
The number of cardiological patients who need urgent qualified help has no geographical differences and constitutes approximately an equal qualitative group in proportion to the total population in all regions of Ukraine.
Nevertheless the differences are startling, and in a number of regions one can talk about total inefficiency of operation of the set of transtelephone electrocardiography, while other regions demonstrate opposite results. Comments of some medical institutions of Ukraine to the work of «Telecard» complex are given in Appendix 1 to this article.
The telemedical diagnostic approach implemented by means of the «Telecard» system due to its novelty and introduced changes can bring to life diffidence and doubts in specialists familiar with it only by hearsay. The success of the equipment implementation greatly depends on skillful administration at the level of region or district, because the telemedicine requires a system approach and rigid coordination of efforts of representatives of various medical institutions. And not in all regions is this coordination as it should be.
On the other hand, the achievement of telemedicine and prospects of its wider implementations irritate and displease some medical specialists and medical businesses close to them due to redistribution of financial flows assigned for purchasing medical equipment at the expense of government programs. Unfortunately, sometimes we have to listen to third persons who retells opinions of anonymous experts, who state that «Telecard» is unsuitable for rural medicine due to insufficient quality of ECG and one must stop purchasing it. And the so-called experts did not work with the device even for a single day and most often even have not seen it. Such critics, as a rule, are not interested in the opinions and high estimates of the specialists who day by day work with «Telecard» for two years.
A thorough analysis of the situation makes it possible to confidently state that the discrepancies in the efficiency of utilization of extremely important for the country population expensive equipment in various regions can be clarified by impartial evaluation of the level of administration of the telemedical network being created, degree of interest, desire to use and control usage of the equipment, manifested by particular health care managers in particular regions of Ukraine.
It would be not out of interest to consider this thesis on the example of the comment on the «Telecard» complex operation, signed by one of the deputy Head of Health Care Administration of Zakarpatskaya region. We must underline that the equipment was installed in Zakarpatsky RCD in Uzhgorod in the beginning of 2005, and since then, according to the data reported by Zakarpatsky RDC, ten CRHs of the region have transmitted only 18 ECGs. It is, without exaggeration, dead frost.
The Deputy Head of Health Care Administration sees the causes of such poor work in the following:
1. «… quality of electrocardiograms ... leaves much to be desired»;
2. «ECG recorders are not functionally complete devices»;
3. «the devices do not meet the requirements of State Standard GOST 19687-89 ... are not registered in the State register of medical technical products».
4. «part of the equipment already failed».
We must note that the given quotations are word-for-word calque of the statements given by E.N.Amosova in her letter from April 26, 2005, to the Minister of Health of Ukraine Mr. N.E.Polischuk (see Appendix 3). The history of this letter has a detective coloring; it will be enough to say that, in spite it is being addressed to a definite addressee and is not an open letter, unknown persons anonymously sent this text in June-July 2005 to all regions of Ukraine. It is credibly known that Ekaterina Nikolayevna herself did not mail the letter and authorized nobody to to this.
This letter contains the information, which groundlessly criticized both the equipment manufactured by LLC «Tredex Company», and activities of GUO «Politekhmed» for purchasing it. The thesises of the letter are grounded on incomplete and doubtful information, obviously presented to Mrs. Amosova by an interested structure. The LLC «Tredex company» gave a comprehensive and detailed answer to allegations in letter out. No.13/06-1 from June 13, 2005, addressed to Amosova E.N. With copies to Minister of Health of Ukraine Polischuk N.E. and General Director of GUO «Politechmed» Devko V.F. The Ministry of Health of Ukraine accepted the explanations, and no further actions were taken as to the letter by Amosova E.N.
The information on the fact that medical institutions received the letter signed by Amosova E.N., sent by anonymous senders, the LLC «Tredex Company» has received from several regional centers. The head doctors who had the equipment successfully installed and operated explained that they have no doubts in the complex efficiency, in contrast to the goals and content of the mentioned letter.
Nevertheless, one year after the Deputy Head of the Health Care Administration of Zakarpatskaya region has digged out the already disproved information and presented it as a claim with his signature to the «Telecard» complex. The denunciations of arguments No. 2 and 3 and, actually, the above-mentioned letter, was given already in June 2005, and there is no need to present them within the scope of this article.
Arguments No. 1 and 4 should be examined more thoroughly. During the entire period of operation of the «Tredex» complex there were no complaints from the Zakarpatsky RDC personnel as to the quality of recorded ECGs. During phone conversations the RDC specialists repeatedly underlined the fact that the quality of ECGs is suitable for cardiological diagnosis. However, the Deputy Head of HCA has doubts about this quality, and, mind, regardless the opinion of the staff of medical personnel in Zakarpatskaya region, who directly works with the equipment.
The statement that «part of the equipment is already failed» is groundless. The LLC «Tredex company» independently renders guarantee services and repairs of manufactured equipment. There were no claims from medical institutions of Zakarpatskaya region to the company as to failed equipment.
Thus, either this statement is untrue and the Deputy Head of HCA does not control the situation, either the medical personnel of central and regional hospitals of Zakarpatskaya region did not take timely measures for repairing the costly equipment purchased from the budget means.
Nevertheless, the situation with utilization of the «Telecard» complex in Zakarpatskaya region is really far from favorable, and therefore the employees of the LLC «Tredex company» have undertaken an independent investigation of the problems that have arisen in this region of Ukraine.
They have found the following. As to September 20, 2006, the equipment was given to nine CRHs and rural ambulatory station in the village of Dubovoe. In their practice only doctors of Mezhgorskaya CRH use «Telecard» for obtaining urgent diagnostic aid.
Doctors of Vinogradovskaya and Khustskaya CRH tried to use the «Telecard» transmitter as a standard electrocardiograph, not understanding the essence of telemedical consulting. They think that they do not heed help from colleagues of the regional center and do not contact them.
Doctors of Svalyavskaya CRH, when there is a complex diagnostic case, summon a car from the regional center and wait when it arrives. They neglect remote diagnosis, which can dramatically shorten the time till the beginning of specialized aid in difficult cases, as well as expenses of budget means on ambulance car travels over distances longer than 70 km.
Tyachevskaya CRH is going to use its transmitting device for working within the district telemedical network, becasue in 2006 a central «Telecard» station was installed in this hospital. At present the preparatory work for adopting Tyachevsky RDC for receiving ECGs from rural ambulatory stations of the region is close to the end.
In Irshavskaya, Volovetskaya and Rakhovskaya CRHs and rural ambulatory station in the village of Dubovoe the transmitting devices are installed in rooms that have no connection to long-distance telephone line, the latter being available in the Head doctor office. Thus, carrying out telemedical consultations is connected with serious inconveniences that hamper normal operation of the system. At the same time, there is no other electrocardiograph in Irshavskaya CRH and Dybovskaya ambulance station, and the necessity of diagnostic consulting is extremely high.
In Veliko-Bereznyanskaya CRH a new Head doctor has been assigned. New Head doctor Markovich V.M. showed a vivid interest in the «Telecard» operation and wants to organize remote consulting on an appropriate level.
Thus, we have the absence of methodical and organizational work of the heads of regional and district health care administrations as to putting into operation the «Telecard» telemedical network and maintaining its workability.
The actual list of causes of poor state of affairs with urgent transtelephone ECG diagnosis in Zakarpatskaya region does not coincide with that given in the letter by the Deputy Head of HCA not in a single item. This fact indicates, that this manager does not control the situation on the spots and shows no interest in organizing the operation of the system, which is highly efficient especially for rural population.
Unfortunately, close scrutiny of the situation in a number of other regions of Ukraine that are also at the bottom of the list as to the efficiency of the «Telecard» complex operation, completely confirms the validity of said above. Among the most serious problems that actually limit the possibilities of the transtelephone complex utilization in Ukrainian medicine there are:
1. Absence of dialing prefixes. Installing the «Telecard» transmitters in places not equipped with access to a long-distance telephone line deprives the system of telemedical ECG diagnosis of any sense.
2. Absence of dedicated telephone number for ECG reception. Installing of the «Telecard» receiving equipment in places with large number of connected in parallel phones substantially hampers the possibility of dialing in to RCH in urgent situation. After several abortive attempts in a situation that requires immediate diagnostic aid the personnel of CRH or rural ambulance stations abandons the attempts to call RDC for a long time.
3. Absence of special wages or combined wages. Absence of any form of compensation for increased diagnostic load of doctors in RDC.
4. Absence of the desire of medical personnel to change a familiar style of work.
5. Absence in the hospital/ambulance station budget means for paying for telephone consultations. This reason is named rather often, but cannot be taken as a serious one. Proceeding from the maximum amounts as to the number of transtelephone consultations registered in Vinnitskaya region, the maximum overhead expenses of CRH for telephone conversations equals 24 Grivnas per month. For a family ambulance station working withing the boundaries of one district with RDC, this sum will not exceed 5 to 6 Grivnas. These sums look ridiculous compared with the amount of social and economic losses of the state due to constant or temporary incapacity of work of citizens, as well as their death due to untimely or unqualified provisioning of urgent medical aid in the course of manifestation or aggravation of a cardiovascular disease.
It clearly follows from the above list of the major problems, which hamper efficient utilization of the complex for ECG transmission over telephone «Telecard», that the solution lies in the plane of increasing the level of administrative guidance of the «Telecard» regional network operation, methodical support, efforts on raising awareness and increasing the responsibility of authorities at all levels.
As a recommendation on increasing the efficiency of operation of costly equipment bought from the state means, we can offer a workshop or round table under the aegis of the Ministry of Health, devoted to the analysis of two-year experience of «Telecard» complex operation in Ukraine. In the work of the work shop the representatives of health care administrations from all regions of Ukraine, all RDCs and most successful CRH and rural ambulance stations must take place.
It seems necessary to investigate the experience of the leaders, study the problems of those falling behind and work out a unique state approach as to the further development of the cardiological diagnostic network. Those who doubt, skeptics and dishonest anonymous critics must also obtain answers at a meeting (conference) in order to place correct accents in the course of open discussion and finally determine the diagnostic value of the «Telecard» complex.
By the way, this value is already asserted by thousands of transmitted ECGs, hundreds of saved patients, who have timely obtained diagnostic aid, as well as expert opinions of specialists and heads of N.M.Amosov Institute of Cardiovascular Surgery of Academy of Medical Sciences of Ukraine, A.N.Bakulev National Center of Cardiovascular Surgery, I.M.Sechenov Moscow Medical Academy, N.V.Sklifosovsky First Aid Research Institute, Russian Association of Telemedicine, dozens of hospitals and cardiological ambulance stations and medical posts of Ukraine.
Basing on the workshop results, methodical recommendations must be formulated for creating and developing the «Telecard» system at different hierarchical level of Ukrainian medicine. Such recommendation must serve as foundation of an order by the Ministry of Health of Ukraine, mandatory for all medical institutions that operate telemedical equipment.
A state-of-the-art, reliable and promising tool has been created in Ukraine, able to really increase the quality of medical aid in rural areas. A priceless practical experience has been accumulated of «Telecard» equipment operation at various levels of medical aid provisioning: «Regional hospital (cardiological dispensary) – CRH», «CRH – rural (family) ambulance station», «System of emergency call service».
This experience needs serious apprehension and shaping of practical guidance of telemedicine development at the highest level; maybe one can talk about a coordinative committee or group at the Ministry of Health of Ukraine. Telemedicine is a new and promising direction in the health care system that require serious attitude of specialists and managers of all levels.
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