Digital Medicine
Digitalization of disease control and telemedicine
Dmitry Krylosov, Alla Baranova, Nag.Ru
No one in their right mind would argue that ease of access to medical services and the possibility of self-diagnosis are of paramount importance for almost every person. And modern telecommunications are ready to give us a real revolution in this field.
The concept of "telemedicine" has entered into everyday life relatively recently, although "online treatment" can include telephone consultations with a familiar doctor, an ambulance call, and cardiac monitoring. It is believed that for the first time in history, the inventor of the telephone, Alexander Bell, resorted to telemedicine services when he called a doctor by phone.
The birthday of telemedicine in the modern sense is March 22, 1905, when Professor of physiology at Leiden University Willem Eithoven – Nobel laureate, inventor of electrocardiography – broadcast a normal electrocardiogram from his home laboratory to the university clinic at a distance of 1.5 kilometers using a telephone cable. And he also used the Latin prefix "tele-" for the first time to denote the remoteness of medical care when he called his system a "telecardiogram".
Willem Einthoven
A little history
Since then, every invention in the field of communication and data transmission has been used for medical purposes in one way or another.
· Already at the end of the XIX century, military doctors exchanged statistical data by telegraph – they passed lists of wounded and killed to each other, sent requests for medicines. They say that this is how field doctors ordered medicines during the American Civil War.
· The telegraph station was located at the home of the legendary doctor Nikolai Sklifosovsky, who actively used it to communicate with patients.
· At the beginning of the twentieth century, stethoscopes were patented in Europe and the USA, allowing transmitting an auscultative picture of the heart and lungs via telephone communication at a distance.
· In 1929, photographic prints of two dental radiographic images transmitted by telegraph were published, while the high quality of the images was noted ("Even filled root canals are clearly visible ...").
· The first television broadcast of the surgical operation was held on May 31, 1949 at the University of Pennsylvania.
· In 1970-80, NASA transmitted clinical data via television in Arizona, Boston, Canada.
· In the 70s, when the opportunity arose, a large program was developed in the USSR to transfer electrocardiograms to special advisory centers.
· Telemedicine "bridges", already at the end of the existence of the USSR, allowed to conduct more than 300 clinical consultations for victims of the earthquake in Armenia in 1988 and to help victims of the explosion of the gas pipeline in Ufa in 1989, providing audio, video and facsimile communication between disaster zones, Moscow clinics and four leading medical centers in the USA.
New technologies are changing the possibilities
It should be said at once that in the modern world telemedicine is inseparable from the digitalization of all processes related to health in one way or another. Doctors will have to abandon paper carriers and branded clumsy handwriting, learn to interact with huge arrays of reference information and use the support of AI-like systems, establish systematic monitoring of patient data in real time.
A typical example from the present, already sprouting into the future: the CheXNeXt neural network processed 420 X-ray images in 1.5 minutes and produced a result, on average, not inferior to the conclusions of professional radiologists, who took 240 minutes for the same work. In some moments, it still gave way to the most qualified specialists, but quite a bit, and this is only the very beginning of the development of specialized analytical systems.
Organization of the process
What should it look like in the end?
The history (illness, health) started on the birthday should be stored electronically, for example, in the "cloud" of a medical institution, the whole thing, from the first entry "born, weight, height", including the first tooth, colic in the tummy, chickenpox, mumps, flu, injuries, operations. The results of examinations, tests, ultrasound, MRI, X-ray. Having a complete picture on hand, the doctor will be able to diagnose and prescribe treatment more accurately. For patients, medical procedures should be simplified and accelerated:
· Making an appointment with a doctor is as easy as buying a ticket via the Internet.
· In the waiting rooms of automated hospitals, patients will be examined using cameras, sensors will determine heart rate, body temperature and respiratory rate, special devices will be able to measure blood pressure and make an ECG within 10 seconds.
· Diagnoses are made ten times more accurately, and the effectiveness of treatment is incomparably higher: AI helps the doctor, remote consultations of highly qualified specialists and quick consultations are possible.
· During the appointment, the doctor will prescribe a sick leave, which he will go to the social insurance fund and to work, and the prescribed medications will be instantly visible to the pharmacist in any pharmacy according to the passport.
· Self-diagnosis will become common and habitual. Mobile apps and wearable devices will allow you to monitor your health.
· After receiving and drawing up a treatment plan, patients will be able to communicate with the doctor remotely, and go to hospitals much less often than now.
· The system will automatically analyze the patient's condition in real time, determine deviations from the diet or course of treatment, and send digital notifications.
Wearable electronics
Constant monitoring of the condition and prevention of diseases are practically impossible without wearable technical means. And they, in turn, are integrated into our lives along with the development of healthy lifestyle: physical activity trackers – bracelets, smart clothes, headphones, glasses, etc. – are increasingly common in everyday life. Medical wearable devices are also becoming more and more every year, their capabilities are becoming wider, and the visibility when worn is less and less. Thanks to the development of wireless communication, gradually everything is going to the fact that even serious treatment will not worsen the quality of life.
Remote monitoring of the condition of patients began to be used not yesterday. But only the miniaturization of wearable electronics and constant communication with the medical network make it possible to realize all the possibilities of this method of patient control.
The first ECG heart rate monitor, Polar, 1977
The world's first sports smartwatch Polar Sport Tester PE 2000 with a heart monitor and alarm clock
Here are examples of modern medical mobile systems.
Health Patch MD is a disposable sensor that can measure and record pulse, ECG, respiratory rate, number of steps, respiratory rate.Dexcom G5 – measures the blood sugar level for a long time and sends this information via Bluetooth to the smartphone application.
Medtronic MiniMed 670G is an automatic insulin pump that partially replaces the pancreas. Continuously monitors the sugar level and, if necessary, injects insulin.A few more examples, just a list:
· Medical Recorder Warp 3 measures a 6-channel ECG, blood pressure, heart rate and respiration, body temperature, pulse, blood oxygen saturation (SpO2), etc. The kit includes an ultrasound diagnostic module with three probes of different types for ultrasound scanning.
· Israeli Cnoga Medical has found a method that allows you to control sugar levels without having to puncture your finger to draw blood.
· Swiss scientists have made a device whose area does not exceed a square centimeter, and which is attached to human skin. It can independently collect, accumulate and analyze sweat, measure the concentration of sodium and potassium, body temperature and pH, chlorine levels and other biomarkers.
· Health Care Originals has created a device that helps monitor the condition of chronic asthma patients remotely and send a signal to medical personnel in case of an acute attack.
· Cycadia Health bra is a method of pre–medical diagnosis of breast cancer. A number of special thermal sensors analyze body temperature and record its slightest changes, after which, with the help of special software, symptoms are detected that indicate certain risks.
· Snore Circle anti-snoring mask works on the basis of bone conduction of sound. With its help, the vagus nerve is stimulated by vibrations. Snore Circle will also be able to act as a sleep tracker, analyze phases and monitor the entire process.
· There are such developments as a small ultrasound device, which only needs a Wi-Fi connection and a smartphone screen.
· PLIS. Cheap portable Chinese spectrometer for checking biological samples. A smartphone is also used for processing.
· VTT Technical Research Centre of Finland has developed a portable device for measuring the level of inflammation at home based on monitoring the concentration of C-reactive protein (CRP) in the blood.
· The American company NxStage Medical has released the hemodialysis system System One. This is a portable hemodialysis system in which ordinary water can be used. The PureFlow SL system will prepare a dialysate from it.
Another interesting direction is spare parts kits, from which you can independently assemble monitoring and diagnostic systems. Relatively inexpensive ($150-300) kits allow you to assemble a design that is not yet in mass production from serious manufacturers. For example, a typical BITalino kit contains an accelerometer, a light sensor, three-electrode cables for EMG (ECG, EEG), a set of wires with two taps for ED and allows you to quickly assemble something that can do and register:
· Electromyography (EMG),
· Electrocardiography (ECG),
· Electrodermal activity (EDA),
· Electroencephalography (EE).
Of course, the abundance and miniaturization of sensors and monitoring systems could not stay away from such a topic as the "Internet of things". And because IoT in medicine, the topic is even hotter than in other areas. According to forecasts of the research company Allied Market Research, the market of the "Internet of things" in the field of medicine will grow from 2014 to 2021 to $ 136.8 billion. The average annual growth rate of the market will be 12.5%.
The legal side of the issue
Protection of patient's personal data
Data leakage is a real scourge of any services provided using electronic systems. But in the case of medicine, the problem looks much more serious, and its solution will require investing much more money and effort. After all, it is the protection of medical secrecy that will become one of the most important problems on the way to implementing the ideas of digital medicine. For example, 46% of Russians do not trust electronic medical cards precisely because they contain personal information.
In September 2017, Veronika Skvortsova at the Eastern Economic Forum announced plans of the Ministry of Health to secure patient data using a blockchain-based system. The data will be stored in a depersonalized form, and each client will have an individual digital key, and he will decide with whom to share his data himself.
And what do Russian laws say about telemedicine?
An attempt to respond to the development of telemedicine in the world was the amendments to several legislative acts adopted on July 29, 2017 in Russia, which, for ease of understanding, were called the "Telemedicine Law".
If we talk about the content of the document, first of all, the legislators have identified a very important point – the primary diagnosis and the appointment of treatment are allowed only with personal contact between the doctor and the patient. But repeated examinations and observation are possible online. In addition, it is allowed:
· Prescriptions, including for strong, narcotic drugs, in electronic form.
· Remote consultations and consultations using medical documents.
· Consent to medical intervention in electronic form.
· The patient can receive the necessary medical documents (copies thereof) in electronic form.
· All medical professionals – doctors and nursing staff - can consult patients online. Remote medical services can be provided both in the clinic and outside it, and the medical organization provides the medic with the necessary equipment for consultation.
Plans for digitalization of medicine in Russia
Plans for the digitalization of medicine have been approved until 2035, in six main areas. These are information technologies in medicine, medical genetics, biomedicine, sports, preventive medicine and healthy longevity.
At the first stage (2017-2019), the infrastructure necessary for the development of small companies will be created. Small companies, in turn, will ensure the flow of high-tech developments and solutions. The second and third stages are also outlined, but in our reality it is impossible to take such a long planning seriously with all the desire.
According to the authors of the roadmap, by 2035, five Russian companies should be among the 70 largest players in the global HealthNet market. Approximately 70% of products and services in this area should have a full production cycle in Russia. And Russia should enter the top 20 countries in the world in terms of consumption of HealthNet products per capita.
Do you believe?
Are our hospitals ready?
I think I won't reveal a big secret if I say that promising and effective technologies are being introduced in our country much slower than modern technology allows. And the bottleneck here is, first of all, excessive bureaucracy. The human factor and, in part, finances also have a significant impact. For example, a former adviser to the President of the Russian Federation on the Internet in social networks said that the main obstacle to the development of telemedicine is compulsory medical insurance (CHI). More precisely, not the CHI itself, but the desire of "colleagues" to get into it and divide budgets. The main link of telemedicine – telecom – technically overcame critical problems long ago.
Today, the medical "top" has little idea who, how and when, will digitize tons of paper, systematize documents and begin to upload them to cloud storage. In addition, it is required to print the documents generated in the computer, and then store the papers in the archive. That is, the electronic version is duplicated by the paper version: after all, only a paper document is legally significant so far.
Nevertheless, methodological recommendations on the technical equipment of hospitals for the provision of telemedicine services have been prepared.
The survey conducted among the heads of medical institutions and doctors is not without interest. Here is a small excerpt from it:
The majority of managers (81%) believe that doctors are ready to learn new technologies, they are ready to provide time for this, noting that they can allocate an average of 21% of the doctor's working time for their training. Doctors believe that they will be able to accompany patients with the help of telemedicine 19% of their time, managers call a close figure of 20%. Doctors are ready to allocate 21% of their working time for training. This is as much as managers are willing to allocate. But, as 52% of doctors noted, now their clinics do not allocate time for staff training. More than half of doctors (55%) are ready to start consulting patients at a distance (for example, in a text chat or by video) if the clinic provides them with special tools for remote communication. While managers believe that only 31% of doctors in the clinic are ready to provide telemedicine services.
EGISZ
Necessary for the development of telemedicine, the unified state information system in the field of healthcare (EGISZ) was approved in the form of a concept by Order No. 364 of the Ministry of Health and Social Development of Russia dated April 28, 2011, and partially began functioning this year. It is assumed that it will store and provide information to both patients (electronic medical records, appointments to doctors and teleconsultations) and doctors, as well as medical officials (monitoring of purchases, supplies and drug residues, data on the state of medical institutions and the situation of health workers).
Since 2014, the Rostec State Corporation has been engaged in the construction of the project together with Rostelecom and the Voskhod Research Institute. In mid-April 2018, the Board of the Accounting Chamber published the results of an audit of the targeted and effective use of federal budget funds allocated for connecting medical organizations to the Internet. The results of the audit revealed a variety of violations, as well as the inaccuracy of data on the cost of work, which allowed PJSC Rostelecom to make expenses with a profitability of 30%.
Nevertheless, the same suppliers will continue to work on the system further. Rostelecom and Voskhod will deal with regional systems, and Rostec will coordinate their interface with the EGISZ core. By the end of 2018, it is planned to connect more than 700 medical institutions in all regions of the country to the telemedicine system. And just to the Internet – all hospitals in the country.
Investments in the deployment of the system in 2018-2019 are planned in the amount of 1.45 billion rubles.
Projects in Russian telemedicine
The topic of telemedicine itself looks promising, and therefore projects based on it appear like mushrooms after rain. The number of them is large, I will give just a few examples to make it clear that this industry in Russia is on the rise.
Yandex.Health is an application and website for online consultations with doctors. Qualified specialists are in touch around the clock.
Service Pediatrician24/7, a project aimed at children's health, offers the services of doctors of the most specializations from all over Russia. "Round-the-clock pediatrician" is available from both desktop computers and smartphones.
Portal A doctor at work who has been working since 2009 has already accumulated enough patients and a large database of consulting doctors. According to the statistics posted on the portal, 537,279 doctors are registered here (including 64 percent of all doctors in Russia). In March 2018, 71011 publications and comments on 105 specialties were posted on the site.
"Central Archive of Medical Images. Teleradiology" is a cloud storage of diagnostic materials, which can be accessed from any device connected to the Internet. In 2017, on the basis of TSAMI Teleradiology, the project "Unified Radiologist" is being implemented, within the framework of which remote consultations (description) of the results of diagnostic studies on life-threatening conditions, studies conducted in district hospitals outside the working hours of a radiologist are carried out.
Back in the spring, two Moscow polyclinics had the opportunity to receive doctor's consultations remotely.
The MegaFon Health service can now be used by subscribers of all operators.
According to the plans of the Ministry of Health, in 2020, about 400 Russian devices will appear in Russian medical institutions – analogues of the American robot surgeon da Vinci. Operations with their help will be available under the CHI. Robots controlled by doctors will help them achieve manipulation accuracy up to 1 micron, which significantly exceeds the capabilities of a conventional surgeon. The Russian development will be cheaper than the American robot da Vinci. The cost of a foreign device is $ 3 million, and a domestic robot will cost 600 thousand rubles.
Needless to say, many consulting medical services also have their own applications for mobile platforms.
I want to believe that telecommunications will be able to create a new miracle for people living in remote and rural areas, traditionally suffering from a shortage of medical personnel.
In the meantime, an experiment has been launched in Russia to assess the quality of medical care through public services. Russians will be able to put their assessment of the work of the medical organization in their personal account "My health". The experiment will last until December 31, 2018, writes "Rossiyskaya Gazeta", referring to Veronika Skvortsova. Let's hope that the results of this work will contribute to the fact that telemedicine will one day receive an excellent rating in Russia.
Telemedicine abroad
The World Health Organization is developing the idea of creating a global telecommunications network in medicine. There are more than 250 telemedicine projects in the world, which by their nature are divided into clinical (the vast majority), educational, informational and analytical.
There were a lot of experiments at different times around the world, but officially Norway became the first country where telemedicine began to be used.
The American Doctor on Demand project is a platform that allows doctors to conduct patient appointments online around the clock using video communication. The peculiarity of the system is that doctors can not only diagnose the disease, but also write an electronic prescription for medicine. The average waiting time for a doctor by a patient is 4 minutes, 97% of all patients expressed satisfaction with the services provided, and the cost of the service is 4-5 times lower than when visiting the doctor in person.
Telemedicine kiosks are becoming an important part of medical programs in the United States. You can ask for help at such a kiosk directly from the workplace, fortunately, the employer pays for the consultation within the framework of social insurance programs.
According to analysts, the American market of such kiosks will grow from 10 thousand "places" in 2015 to at least 36 thousand in 2020. The American company Capital Blue Cross, specializing in medical services insurance, announced that, starting in 2016, most tariff plans will introduce the ability to use the services of such "kiosks". Usually, one visit to the kiosk costs $49, but for citizens insured with Capital Blue Cross, a consultation will cost $39 per visit.
The British Ambulance service East Midlands Ambulance Service (EMAS) was able to save £40 million and cancel 116 thousand unnecessary calls in a year thanks to the Odyssey clinical support system of Advanced Health & Care.
In the Netherlands, thanks to telemedicine, the number of hospitalizations decreased by 64 percent, outpatient visits – by 39 percent, in the United States – by 19 and 70 percent, respectively.
International networks of medical telecommunications are also being developed, aimed at various purposes: the system "Satellite" – for the dissemination of medical knowledge in developing countries and training, "Planet Heres" – the system of global scientific telecommunications proposed by WHO, international scientific expertise and coordination of scientific programs, other systems and networks.
The largest provider of telemedicine services in China plans to launch a network of mini-clinics the size of a telephone booth, which will be equipped with artificial intelligence. Such a "techno-doctor" will analyze patients' complaints and send them to a fellow doctor. The latter will make a diagnosis and write recommendations that will be passed on to the patient.
Now the shortage of doctors is one of the main problems of Chinese healthcare, and that's just how AI can solve it.
Alibaba's medical division has already attracted 23,000 doctors, pharmacists and nutritionists to conduct online consultations. And 28 million people have registered in the My Health mobile app.
Even from these examples, which make up only a small part of the telemedicine industry, it is clear how it is developing and gaining strength.
Statistics and finance
Information technologies generally come to all branches of the economy and science. Medicine is no exception here, and even eternal medical conservatism is retreating under the pressure of hitherto unprecedented opportunities. And the statistics confirm this – the global telemedicine market demonstrates a confident growth dynamics.
The market leaders continue to be the USA, Europe and the developed countries of Southeast Asia.
According to BCC Research, the global telemedicine market is growing by 18-21% per year and will reach $40-55 billion in the next 3-5 years (however, there are other estimates).
The main drivers of growth are the trends towards the aging of the population in combination with an increase in life expectancy, the high cost of traditional medical services, the spread of Internet technologies and technologies of "smart things".
According to experts, the potential of the Russian telemedicine market is about 18 billion rubles a year.
According to the forecast of Frost & Sullivan, medical AI will become one of the main trends of 2019. The market for such technologies will overcome the $1.7 billion milestone. The main areas are diagnostics, risk assessment for patients and the development of new drugs.
Instead of an epilogue
Telecom operators have long and firmly established themselves in such markets, not too traditional for themselves, as television and telephony, are actively developing video surveillance systems, all kinds of alarms and in general the entire security-related sector, have already partly climbed into the housing and utilities sector, creating opportunities for monitoring and monitoring of resource metering devices. And ahead, in the near future, an endless mass of various IoT devices and IoT services is already piling up, obscuring all imaginable horizons.
Telemedicine will become one of those growth drivers that will make the Internet of Things as close and understandable as possible to the widest range of users, will open and make common new types of services related to the maintenance of wearable sensors and devices, will provide new sources of income. And even though it is still unimaginable to an ordinary operator how it is possible to extract direct profit in this sector, the consequences associated with it will actively affect the market in the next decade.
In this regard, it is extremely interesting: do operators already see their place and their role on the approaches to the "gold mine" of telemedicine?
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