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Telemedicine in cardiosurgery

The experience of telemedicine technology in the modern practice of cardiosurgery

Authors: Knyshov G.V, Ostashko V.G, Siromakha S.O, Truba J.P, Rudenko M.N, Lazoryshynets V.V.

Application of remote telemedical techniques for many health systems in the world are already familiar, the leading scientific, medical and educational centers without this technique can not exist, let alone compete on the market providing medical services. The introduction of telemedicine in the health system in Ukraine in recent years with the support of leading institutions of the National Academy of Medical Sciences of Ukraine and the Ministry of Health takes the form of regular and routine work.

Prospects for the use of telemedicine technologies to meet the basic directions of reforming the health system, foremost among which is to improve the quality, accessibility and timeliness of care to the population. Another important factor - cost optimization subject to efficiency. The best example of fruitful cooperation in this direction can be called an example of the use of telemedicine technology in the modern heart surgery practice. With a common initiative of the National Institute of Cardiovascular Surgery. Amosov MUCH Ukraine and the State Clinical Research Telemedicine Center has organized and conducted the first long-term counseling of children in regions of Ukraine's leading heart surgeons and cardiologists of the country. To do this, have been involved equipment and telemedicine networks National Centre for Telemedicine. Especially interesting is the experience of the session, the remote consulting experts institute cardiac surgery of children with congenital malformations of the cardiovascular system, living in Transcarpathia. This session is the first in the country remote consulting children in the mode of «on-line» gave an opportunity to show the effectiveness and appropriateness of the use of telemedicine technology in cardiac practice. Within a half hours was consulted 11 children aged from 2 weeks to 15 years. Consultation was held with the participation of the attending physician of the patient, who represented all the data about patients, showed the results of laboratory and special methods of examination. During the consultation a number of patients recommended for admission to highly specialized cardiosurgical center for surgical intervention. Another suggested that observation and outpatient treatment in the community. Formulation of a preliminary diagnosis in the neonatal period with the possibility of timely cardiosurgery significantly reduce mortality and are the key to early prevention of disability in these patients. In addition, patients who did not require treatment in hospital cardiosurgery receive all the necessary recommendations for outpatient care and the subsequent further examination. Consequently, telemedical consultations cardiosurgeons patients with congenital malformations of the cardiovascular system of the Carpathian allow rational use of high-tech and intellectual resources of the National Institute of Cardiovascular Surgery, Amosov, which is located in Kiev. In this case there was no need for organizing the delivery of patients to the system "sanaviatsii, arrival of patients and accompanying persons in Kiev, or the departure of physicians for consultation in Transcarpathia.

The first real experience of practical use of telemedicine in cardiac practice proved that the use of modern information and telecommunication technologies significantly reduces the duration of time setting up a preliminary diagnosis of the direct provision of adequate medical care - in this case cardiosurgery. On the other hand, telemedicine to remotely monitor the patient to whom surgical treatment is carried out. It is very important, because someone, no matter how the surgeon who performed the surgery, knows all the details of the disease and the patient's healing process.

Separately, to mention another important aspect - sharing experiences. This is quite important, because during the telemedicine consultation was being discussed for each clinical case between experts from the region and consultants from the Institute. Implementation of such discussions is part of the learning process of physicians, regardless of the location of medical practice and the location of medical facilities.

Consequently, the development of distance counseling provide an opportunity to bring highly skilled and specialized, particularly cardiac surgery, helping leading medical institutions, centers and clinics in remote areas, and significant savings in the cost of providing it. This confirms the fact that telemedicine is a key factor in building a unified medical space and aims to unite together all the elements of the country's health.

Teleconsultation was successful!

For the first time in Ukraine on the base of the State Clinical Research Center of Telemedicine of Ministry of Health of Ukraine (Kiev) and the trans-Carpathian Regional Clinical Hospital (Uzhgorod) specialists from the National Amosov Institute of Cardiovascular Surgery of Sciences of Ukraine held remote consultation of children with congenital heart from the Carpathian region. This event, took place on March 16, 2010, was made possible thanks to the support and the direct of the Deputy Minister of Health, m. d., professor Lazorishinets Vasily and MTS.

During 2 hours eminently qualified specialists from the National Amosov Institute of Cardiovascular Surgery of Sciences of Ukraine remotely consulted children 2 weeks to 15 years old with congenital heart disease.

Prospects of teleradiology in Ukraine

The aim of this work. Radiation diagnosis - the most telling example of the maximum and the rapid integration of advanced technology development and information technology in health care. The number of radiological studies is growing from year to year. New methods and opportunities of old. Even now, no surprise digital rentgenapparatami or digitizer, CT, MRI, ultrasound, a variety of methods. At the approach of PET, PET-CT, etc. Number of diagnostic information, which comes to a doctor, radiology, growing in geometrical progression. As the doctor to deal with so much information? How to sort? How and where to store? In addition, significant is the question of training, which can fully utilize all the possibilities of modern medical diagnostic devices.

The aim of this work - to show the role of teleradiology in addressing these issues and assess the feasibility of its introduction into clinical practice in Ukraine.

Materials and methods. In this paper we use the aggregate statistical data on the radiological service of the country over the past 5 years, regulatory documents and materials on information technology in health care.

Discussion. The number of radiological studies in the country is steadily approaching the 100.0 million: The number of radiological investigations (X-ray, x-ray, fluoroscopy, special techniques), held annually in medical institutions of Ministry of Health, is currently about 50.0 million, the number of ultrasound examinations close to 25.0 million , several times over the past 5 years, increased mammography, computer and magnetic resonance imaging. Every year the number of diagnostic equipment in hospitals. As a result, there are problems with the storage of information, transfer of appropriate medical units and institutions, increasing the cost of processing film (if not digital) and other expensive consumables. Only for the purchase of X-ray films for medical institutions of Ministry of Health annually requires more than 10.0 million dollars. All this happens simultaneously with the negative processes in the staffing of radiology: the small increase in the number of specialists of ultrasound diagnostics, which occurs largely at the expense of radiologists, the number of X-ray every year is declining, and the system of training in computer and MRI do not keep up with the rate of equipment in health facilities. It should also be said about the substantial difference in the intensity of the use of diagnostic equipment in hospitals: the average load on Ukraine to fluorography - less than 15.0 thousand a year of research, there are regions where the rate exceeds 20.0 thousand at rentgenapparat - respectively 5.0 and 6.5 thousand on CT scan - 3.0 and 5.5 thousand in the ultrasound scanner - 7.0 and 12.0 thousand. Consequently, there are institutions where research is very small, which leads to a decrease in the level of professional expertise.

Many hospitals today are faced with the problem of a lack of specialist radiographers, not to mention the problems of financing. One solution to these problems is to integrate modern information technology in health care facilities, their departments and public health in general.

At the time, especially for medicine were developed by 2 standard: Digital Imaging and Communications in Medicine (DICOM) - Standard for the transmission of radiological images and other medical information between computers, which helped to unify the presentation of medical data (images) obtained using different diagnostic equipment producers, and Health Level 7 (HL7) - the standard of exchange, management and integration of electronic health records. This led to the rapid development of software to work with medical imaging and any other data, with the result that the market has a new and very useful product - Picture Archiving and Communication System (PACS) - a system of transmission and archiving of images. As part of the diagnostic department, or even the entire medical establishment, the system allowed to store any amount of information, as quickly as possible transfer of doctor and non-stop access to the archives, with significant savings in financial and material resources by reducing the cost of the special facilities for the processing of films and archives , the exemption from the use of reagents and other consumables, as well as optimization of staff. Typically, overseas PACS work as information systems at a higher level: radiology information system (RIS) - an integrated system for handling radiological images and the Hospital Information System (HIS) - Hospital Information System - optimizing the functioning of the entire medical establishment. In fact, we are talking about all the processes of informatization in the clinic or hospital, not to mention the organization of the X-ray services.

To a large extent the problem of shortage of staff and ensure equal access to health care allows people to decide telemedicine (telemedicine), based on the use of modern computer and telecommunication technologies to address the exchange of information among medical professionals to improve the quality and availability of diagnosis and treatment of specific patients. One of the goals of telemedicine is the transfer of medical images over a distance for remote consultations. With regard to radiology instead of «Telemedicine» uses the term «teleradiology» (teleradiology), which refers to electronic transmission of radiological images from one geographical location to another location for subsequent interpretation and consultation. One of the most promising directions, which allows you to find a reasonable compromise between the increase in the cost of modern diagnostic equipment, training the necessary number of qualified specialists, and financial capacity of consumers of health services - to create virtual radiology networks - Virtual Radiology Network (VRN). European Association of Radiology has developed guidelines for appropriate use and structure of Teleradiology services, which once again confirms the understanding and interest in the medical community in the further development of teleradiology.

Ukraine already has certain conditions for effective use of information systems in medicine and in particular in radiology. Already more than 1000 digital x-ray and rentgenapparatov, computer and MRI, mammography, ultrasound scanners allow maintain and transmit data in digital format DICOM-standard. There are examples of the use of PACS and similar original software solutions for medical facilities for the storage and processing of medical images. Actively introducing telemedicine technology in the aspect of the transfer of medical images for subsequent interpretation and advice in the tertiary institutions. In general, there is a clear prerequisite for the introduction of teleradiology in clinical practice. Among those also include the approval of the Order of Ministry of Health of Ukraine from 25.07.08 № 409 of the sectoral program «Electronic registration system and the exchange of medical information among agencies and organizations of health». Within this framework, and the branch of teleradiology can be a powerful impetus to the development of advanced radiation in diagnosis.

Unfortunately, to date, the transfer of images over telecommunications networks is not given due attention, so purchases of imported equipment option in the telecommunication network (DICOM-option), even if there are not activated, and therefore Teleradiology use of this equipment is problematic . So now, on the one hand, we can talk about nobhodimosti included in the delivery of purchased equipment radiological DICOM-option, and on the other hand, the possibility of the introduction of teleradiology in clinical practice today, on the basis of working in health care settings of digital x-ray equipment domestic production. Currently in Ukraine there are more than 800 digital x-ray systems, including most of the domestic production, while more than 500 systems have the same interface workstations rentgenolaboranta and X-ray that allows the exchange of information between them in electronic form.

For a quick introduction of teleradiology must make the appropriate changes and additions to the regulations. For example, the latest edition of order MH of Ukraine «About the improvement of the organization of radiation diagnosis and radiotherapy» dates from 1997 and it did not adequately reflect the current trends, not only the use of teleradiology, and information technology, telecommunications in the beam diagnostics in general. In addition, at present the Ukrainian Association of radiologists developed standard requirements only to the digital x-ray equipment, among which is the requirement of storage and data transmission in the DICOM-standard. It is sensible to develop similar requirements for all radiological equipment and to legitimize their order of the Ministry of Health.

Another problem - the lack of training, skills, knowledge of electronic systems, storage, transmission and processing of medical information in the X-ray diagnostics, as well as lack of awareness and lack of motivation for use in everyday practice, such systems as the experts, and leaders of different levels . All this hinders the further improvement of the quality of diagnostic care and the introduction of advanced technologies in the health care system. Two years ago at the Department of Radiology, National Medical Academy of Postgraduate Education to them. PL Shupika courses thematic improvement «in Digital Radiology», where X-ray training and backup systems and data, but for some reason on these rates declined, although the obvious need for training radiologists to these issues.

Conclusions. In summary, there are a number of problems whose solution is a prerequisite for the successful development of teleradiology in Ukraine, namely:

- Transition to digital X-ray and the use of modern diagnostic equipment with the option activated in the telecommunication networks;

- Development, implementation and use of special software for the integration of radiological services in a single electronic system for registration, exchange and storage of medical information and, in particular, the radiological images;

- Develop new or adapt existing regulatory frameworks in the health aspect of wider use of modern information technology, international and national standards in radiation diagnosis and telemedicine;

- Organizing and providing training, knowledge of the foundations of robots with advanced equipment and software for transmission, storage and processing of medical information (medical imaging);

- Sensitizing the medical community and industry leaders about current capabilities of modern radiological equipment, provided the latest scientific advances in medicine.

Creation of electronic system of exchange of medical

x
Title of Project Creation of electronic system of exchange of medical
information.
Name of Institution and adress State Clinical Scientific-Practical Telemedicine Center UKRAINE; 03680 Kyiv, pr. Komarova Str. 3
Type of institution Public Administration
Institution profile State Clinical Research Telemedicine Center is a specialized institution for health care, which is subordinate to the Ministry of Health of Ukraine. The aim of Center is rendering high-skilled assistance using modern information and telemedical technologies, their designing, approbation, implementation and development of telemedicine in Ukraine.
Main subject of activity KEY WORDS:
Telemedicine Nformation Technologies
Project desription The aim of this project is creation of electronic system of registration and exchange of medical information between institutions for health care on the base of information and telecommunication technologies. This project can fulfill the following functions:

To increase quality and efficiency of medical care;

To create the base for connected health data- electronic health data
registration and exchange system between medical care providers and
healthcare institutions;

To simplify the implementation of insurance medicine by creating
contemporary Information and Communications infrastructure of the sphere
and electronic register of patients and consultations they were provided;

To optimize and to simplify accessibility of citizens healthcare as much as
possible irrespective of location and registration by implementation of
electronic health record cards for patients;

To increase safety of patient by minimization of mistakes during data
collection and data handling relating to human factor;

To reduce healthcare costs and to increase the efficiency of planning in
healthcare system by time saving of collecting reliable statistical data;

To implement continuous monitoring of processes relating to social and medical provision of Ukrainian people.

Stage of project Development has been started

Type of sought partner Int’l Organization Consultancy
SME
The area of expertise Our industry expertise lies mainly in the fields of:

Information Technology. Our team has significant expertise in sourcing
profiles such as technical support specialists, system administrators,
architects, project managers. Our consultants focus also on the importance
of the candidates having a strong business understanding.

Telecommunications. Our expertise lies in both infrastructure/networking, to
customized software and security solutions (intrusion, firewalls,
authentification), from support engineering level to middle management.
Contact person Forename and surname VITALIY OSTASHKO
Contact details Ukraine, 036803 Kyiv, pr. Komarova Str. 3 Tel./Fax +38 044 4043475 telemedkiev@gmail.com

Institutional and management aspects of telemedicine network

VG Ostashko, GA Light, M. V. Zvyagintsev, A. Kovalenko

Introduction. Development of telemedicine technology to create a legal framework for their implementation, development of relevant documents that regulate the functioning of telemedicine networks providing telemedicine services, conducting distance learning, financial security and so on. International experience shows the introduction of telemedicine, which is true is the organizational structure of telemedicine networks can provide high impact in the provision of medical services in remote areas of the country in emergency situations.

Main results. The first task in the development of telemedicine - a creation of telemedicine network. Telemedicine network (TMM) - a hierarchically organized within a specific territory (district, region, country) system telemedicine centers, points and classrooms are equipped with specialized software and hardware and trained personnel to provide telemedicine services through various types of communication channels 'communications [1]

Tasks to solve TMM:

assist doctors working in remote areas of the country;
accelerate and simplify the management and distribution of documents in the field;
remote training and counseling sessions with employees medychnykamy;
TMM can combine all types of health care facilities - from regional hospitals to the regional offices and the MOH of Ukraine.

TMM must meet requirements for systems that provide telemedicine services:
zabezpechyvaty access to all services kruhlodobovo;
effectively protect private information and to identify users TMM.
provide the necessary geographic and functional expansion of TMM;
provide necessary and sufficient features to meet the challenges of diagnosis, treatment and rehabilitation of patients, teaching and training medical staff and the collection and dissemination of management information;
implement a single medical information space for all participants in the network;
based on informatsiyniyy infrastructure of medical facilities and institutions that are members of the TMM using medical information systems.
Therefore, you can determine the actual direction of institutional arrangements that should accompany the process of creating a telemedicine network in Ukraine. These include:
development and approval of regulatory and legal framework of telemedicine;
development and approval of accounts and reports relating to telemedicine, and their electronic equivalents on the basis of modern information standards;
definition of technical equipment and information and software, ranging from user level (LPZ) to the level of regional telemedicine center, creation of conditions of introduction and storage of medical information;
development of standards for telemedicine services;
definition of domestic and foreign partners TMM Ukraine;
determine the sources of financing telemedicine.
Stop at each of them. First review the development and adoption of legal framework Telemedical. It consists of several levels of legal documents and several units that should regulate the activities of telemedicine in Ukraine:
evidence to conduct telemedicine consultations and «telemedicine care» population;
Voluntary informed consent of the patient (or relative or person who acts on behalf of the patient) on the use of personal medical data in a telemedicine consultation;
consultant responsible for the conclusion made in terms of his whole complex of information on the status of the patient and the doctor performing the right obtained by telemedical consultations recommendations;
autentychnist medical records that are discussed (the same as the confirmation provided / received);
authorization materials obtained using telemedicine consultations;
telekonsultatsiyi confidentiality and protection of personal data following the patients;
protokolizatsiya (documentation) telemedicine consultations, and following arhyvuvannya data telekonsultatsiyi;
authentication consultant and his signature;
technical timely conduct telemedicine consultations, responsibility for the accuracy of information that is published on the Web-servers;
ensuring the copyright and property of the materials used in telekonsultatsiyi;
provide paid telemedicine services [2].
Thus, the priority for the introduction of telemedicine technology is legal acts (first of all, the law) of telemedicine, where rehlamentuyusya basic provisions for telemedicine in the light of the patient and doctor (in the absence of laws on the rights of the patient, medical institution, etc.).

Regulations (the Cabinet of Ministers of Ukraine Ministry of Health orders) should govern the practical implementation of the telemedicine. This includes decisions and orders of the telemedicine network, the rules of its operation, orders approving accounting records for telemedicine consultations, definition of performance indicators of different levels of telemedicine.

Another important development is the introduction of telemedicine accounting records. References such documents was given by us in [3].

Particular attention in the drafting of documentation for telemedicine consultations should give them electronically. Today, electronic medical records (EHR) is dedicated to many studies in different countries. Created hundreds of variations of such documents. However, the international community regulates the creation of such documents based on specific information standards. First of all, this is standard transmission, storage, archiving of medical data and presentation of electronic medical records. These include standards such as Health Level 7, which is aimed at standardization of formats of medical data between medical institutions, open EHR, which regulates the way to create electronic medical records, DICOM, which regulates the storage formats and transmission of medical images and a number of International Organization for Standardization (ISO), governing the format of electronic health cards, etc.. In the development of information support is also necessary to apply a series of classifiers and directories to be departmental standards of health. These include a classifier, as ICD-10 Classification of health services, surgeries and other procedures.

Health Level 7 - standard for health information exchange application-level communications between information systems in health care. Exchange information (version 2) is usually between information systems in the same hospital, between hospitals and clinical laboratories that are outside hospitals. Today, this standard has the version 3, which specifies the architecture of electronic medical records and their transfer. Used in the U.S., Australia, most European countries.

Standard CEN \ ISO 13606, in other words open EHR, offers a way to standardize electronic medical records based on the so-called archetypes and templates. Today, he is only beginning to apply in countries such as Australia, Britain, Sweden.

For transmission and storage of medical images currently widely used standard DICOM, through which the transmission of medical images with digital diagnostic devices (x-ray machine, ultrasound, scanner, CT, MRI, etc.). Today, on the basis of this information, most standard operating systems such as PACS (Picture Archiving and Communication System), which function in almost every medical institution developed countries where the introduction of telemedicine systems [4-8].

Software and hardware platform telemedicine facilities should be established based on typical automated workplaces (AWP TM) specialist doctors, leaders of other centers using the channel not less than 512 Kbps.

ARM TM should include the following information and tools:
Electronic patient card for remote consultation;
E-book accounting telemedychyh consultations;
Specialized software for telemedicine consultations;
Information system for archiving and storage of medical information and images (PACS);
Module connection of medical diagnostic equipment from the workstation user.
In the telemedicine network storage and data processing must be divided into three main modules:

- Medical service (MS) - responsible for the accumulation and storage of all medical information.

- Workstation (PC) - responsible for processing and diagnosis in the accumulated MS images.

- Remote work station (VRS) - responsible for processing and diagnosis in the accumulated MS medical images in institutions beyond the telemedicine center.

The three main modules to be integrated using the DICOM-protocol with existing devices, digital input image, quality control and other digital equipment.

Thus, a telemedicine network in Ukraine is necessary and the real project. To create the necessary development, availability and combination of the following components:
Planning the network structure;
necessary computer equipment;
availability of DICOM-compatible software.
strategy development of the network.
Solving this problem can not be outside the general field of informatization strategy for telemedicine network will only be effective if the project will be integrated into network sharing medical data.

[center] Literature [/ center]

Vladzymyrskyy AV The basic concept of telemedicine in health care / / Ukr.zh.telemed.med.telemat.-Vol.5, № 3.-2007.-S.244-251.
Naumov VB, Savelyeva DA Legal aspects телемедицины. Under scientific editors, Professor RM Yusupova and Professor Robert I. Polonnykova - St. Petersburg.: SPIIRAS, 2002.-106 pp.
Organization of telemedicine in the health institutions ozorony (guidelines) / / MV Zvyagintsev, AV Vladzymyrskyy, VG Klymovytskyy, GA Light, L. S. Godlewski, V. Ostashko .- MH of Ukraine .- 2008 .- 70 pp.
ISO / TS 18308: Health Informatics - Requirements for an Electronic Health Record Architecture, 2003;
ISO TC 215/WG 1: Health Informatics - Electronic Health Record-Definition, Scope and Context, Draft Technical Report, 16.3.2004;
The openEHR EHR Reference Model - Revision 4.3.2, The openEHR Foundation, 2003 (www.openEHR.org);
Dolin RH, Alschuler L, Beebe C et al.: The HL7 Clinical Document Architecture. JAMIA 8 (6) :552-69, 2001;
Hussein R, Engelmann U, Schroeter A, Meinzer HP.: DICOM Structured Reporting: Part 1. Overview and Characteristics. Radiographics 24 (3) :891-6, 2004.

Application of standards in telemedicine network

Kovalenko, OS, Ostashko VG, Kozak LM, Neschadin SI

Development of telemedicine technology in Ukraine requires the use of uniform methods of communication between actors telemedicine network. This is primarily the need to support a single medical information space, on the other hand - the requirements of international partners.

As is known, the most common method of telemedicine consultations are delayed telemedicine consultations. During these consultations to the medical records and medical images.

Medical records or medical documents, of course, must be in electronic form or be translated into electronic form of paper media. Thus, for communication in telemedicine network should be developed electronic versions of the relevant registration forms. Now in Ukraine, making the data are only on paper media. Forms must not only be designed and coordinated at the level of the MOH of Ukraine. In the case when working with electronic copies of paper documents, we view them as pictures or medical images.

Today in Ukraine only started to develop such electronic documents for telemedicine consultations, made certain projects which are at different levels of implementation.

The international community in telemedicine networks for the transmission of medical records and documents using one of today nayrozpovsyudzhenishyh standard Health Level 7. This standard applies in the U.S., Europe, Australia, South America, some Asian countries. It also localize and Russia. The second version of HL7 enables standardize the process of medical records and documents between medical institutions and various information systems. Performance of this standard to success.

In Ukraine, now also work on the localization of this standard.

Another standard application is available in Europe and the U.S. and other countries, is DICOM (). This standard is designed for transferring and storing medical images. Now 95% of digital medical diagnostic equipment is DICOM-console, which lets you use them for telemedicine consultations. Before that, virtually all PACS applying this standard. Ukraine today also lokalizuye this standard for its use in information networks.

Another standard reference is the standard for SCP-ECG, developed by the European Institute for Standardization (CEN). Document ENV1064 is an official standard SCP-ECG (Standard communications protocol for computerized electrocardiography) European Union This standard establishes a single protocol ECG data between digital electrocardiographs and computerized management system, and between computer systems.

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