Telemedicine in Russia: Is it the Saving of the Patients or a Fiction pushed forward by the Officials?

But will Russia be able to make the jump into cybermedicine when doctors still sometimes can't even get to patients because of bad weather and road conditions?

Victoria Pavlova

Recently, Minister of Health Mikhail Murashko announced official data on the shortage of doctors. They turned out to be even worse than previous independent estimates. The trade union of healthcare workers in Russia believes that there is a shortage of 30% of specialists, this is about 20 thousand doctors. But according to the minister, the shortage of doctors in Russia is 25,000–26,000 doctors and about 50,000 paramedics. Increasingly, the authorities, especially in the regions, are offering to deal with the lack of specialists with the help of telemedicine.

At first glance, the ideal solution in case a person does not have the opportunity to get an appointment with a doctor. For example, a pensioner who, due to his age, finds it difficult to travel somewhere and stand in lines, and you cannot provide every godforsaken village with three houses in the Siberian taiga with doctors. But with telemedicine, this is not required: I talked with the doctor remotely, took measurements of my health using modern technology, and received an appointment for treatment with an electronic prescription. In theory it's beautiful. Novye Izvestia tried to figure out what in reality they are trying to offer us under the sauce of telemedicine.

The cyber future turned out not to be cyber at all

Experts are in a hurry to destroy the pink dreams of a great cyber future for the benefit of health. Andrey Almazov , director for project activities of the Association "National Base of Medical Knowledge", believes that there is no "telemedicine" at all:

- This is a conditional concept, necessary to increase attention to the new entity in the old system. Federal Law 323 defines telemedicine as "the provision of medical care using telemedicine technologies" and further deciphers telemedicine technologies as remote interaction technologies. There are no new features here. There is a doctor, there is a patient, there are means of communication that have now become available to them. Accordingly, the doctor and only the doctor must decide what he can do remotely and what not. This is a simple logic that the regulator (Ministry of Health) categorically refuses to recognize.

So actually the promised telemedicine is not at all home treatment without the physical presence of doctors. The authorities of many regions, especially the northern ones, report on the success of telemedicine consultations. The head of Yakutia, Aisen Nikolayev, tells how telemedicine facilitates the work of doctors and saves residents of remote areas; in the Tula region, thanks to teleservices, the life of a person with coronary heart disease was saved. But what exactly they are, the head of the Kuzbass Ministry of Health Dmitry Beglov recently said: he promises only the opportunity for local doctors to contact and consult with specialized specialists from larger centers. Everything. Telemedicine is now working in this format, at least officially. For example, in the Ivanovo region since 2019, about 600 patients have received telemedicine consultations from doctors from federal centers. But it was local doctors who communicated with specialists and made diagnoses. Andrey Almazov adds that there is nothing new in this:

- Possibility of consultation of a FAP paramedic or a doctor of a small outpatient clinic with a more experienced colleague from the NMIC or other institution organized in the public health system is a blessing and a step forward. Only this is in vain defined as “telemedicine”, this is a long-known consultation or, more precisely, “supervision” (when a more experienced doctor, upon request, helps a less experienced doctor with his opinion on the patient’s clinical situation).

The future is only in Moscow

But the head of the Department of Information and Internet Technologies, Moscow State Medical University. Sechenov Georgy Lebedev argues that counseling has made a qualitative step forward. It’s no longer just asking a colleague’s opinion:

- There is a new area of consulting, for example, in radiology based on the results of examinations. A Center for Radiology and Telemedicine has been established in Moscow, which receives information, X-rays, CT, MRI, etc. from Moscow hospitals and polyclinics. And the doctors of this center write conclusions and send them to where this study was done. Similarly, there is a decoding of cardiograms and other solutions, and a set of these data, in turn, allows you to create artificial intelligence systems that can find these solutions automatically.

The introduction of artificial intelligence is really a new word in medicine. But this intelligence does not live in an unprepared environment. Konstantin Khomanov, founder of the Medical Decision Support Service “Doctor's Handbook”, notes that the technical equipment of medical institutions in Russia is very different. Sometimes telemedicine technologies are simply not available:

- There is no complete readiness for the development of telemedicine in the country. Everywhere is different: somewhere doctors are given personal tablets, and somewhere there are only a few technically appropriate computers for the entire hospital.

Where have all the doctors gone?

Attempts to replace the shortage of doctors with telemedicine sometimes look simply ridiculous, because even remote consultations still have to be provided by real doctors! Boris Zingerman, head of digital medicine at Invitro, notes that today there is no understanding of who and how will conduct telemedicine consultations and remote monitoring:

- Remote monitoring is the new type of assistance that doctors are required to provide to their patients. Previously, this was not the case, now it needs to be added, while all previous duties are not removed from the doctor. That is why the most frequent question of doctors about monitoring is why do we need it? That is, for patients, especially for the chronically ill and the elderly, the topic of constant monitoring seems to be the right one, but for doctors this is an extra burden that needs to be built into the overall burden, to understand how these services will be charged, and since this is a new topic, all this is moving forward very difficult.

Finding doctors willing to take on the extra workload is not a trivial task. Where did the doctors go, and why is the shortage of medical staff not compensated by young specialists, because medical universities have not disappeared in Russia? The educational institutions themselves did not close, but there was a big drop in the number of students and graduates. According to the academician of the Russian Academy of Sciences and professor of Moscow State University. Lomonosov Sergey Kolesnikov, the situation with admission to medical universities began to be corrected only in 2015. And by 2020, student enrollment has increased by 1.5 times to 64 thousand people. The situation is similar with the training of nursing staff. But training a doctor is a long process. Current students will only come to hospitals in larger numbers after 2026. In addition, people want decent wages. And therefore, according to Georgy Lebedev, many leave to work in other areas:

- In my opinion, universities graduate enough doctors, but many graduates do not want to go to work far from Moscow, many go to pharmaceutical companies. There is also a shortage of doctors in commercial clinics; this is not only a problem of state medicine.

The most difficult thing is in rural areas, says Ekaterina Rubezhova, a dentist at the Confidence clinic:

- Wages are lower in rural areas. This is the main reason for the shortage of doctors at the moment. In large cities, the shortage of doctors is much less in comparison with the regions. In addition, about 38% do not go to work in the medical specialty after graduation. There is also professional burnout, when, after a certain accumulated experience, doctors leave the specialty.

And the root of the outflow of doctors from rural areas, according to Sergey Kolesnikov, lies in the May 2012 decrees: "territories to megacities and prosperous regions of Russia”.

For the development of telemedicine, people are needed, funding is required. But the government carefully ignores this. Sechenov University notes that public medicine has a complex multi-channel financing system - there is no single source of funds. Therefore, it was possible to obtain funding (and at the same time put a plan for providing telemedicine consultations) only to the National Medical Research Centers (NMRC). In reality, it looks something like this: NMICs were given some amount of money and set a plan to process a certain number of telemedicine requests. But this does not solve the whole problem, because the existing small number of doctors in the wilderness, in the absence of specialized specialists, is forced to spend time reaching out and sorting out the diagnosis with experts from the NMIC. Time is wasted on consultations of specialized specialists in the largest medical centers, although suitable ones may be, for example, in the nearest hospital. They can also advise the conditional paramedic and his patient. But no one will pay them anything for additional work. So it turns out that for the government, telemedicine is just a way to save money. A classic bureaucratic approach based on the principle of “feed less and milk more”.

It turns out that the new direction does not have a full-fledged source of funding, doctors received an additional burden (at the same time, deputy Oleg Leonov noted that 60% of doctors work at 1.5 rates, and 12% of doctors - at 2 or more rates), and federal and regional the authorities only care about how to save money, and at the same time promote in the media on new technologies, which in most cases turn out to be not so new. You won’t surprise anyone with a messenger now.