A.V. Vladzymyrskyy, V.G. Klymovytskyy Telemedicine in Ukraine Nowadays in Ukraine we face the active implementation of computer and telecommunication technologies in the health care service. First telemedical work-outs appeared in our country in 1970ies. They mostly concerned telemetry of physiological parameters for miners. Today telemedicine is basically developed as teleconsultations and distant learning. Theoretical elaborations In 1999 we published the book under the title “Introduction to Telemedicine”, which appeared to be the Ukrainian work, considering theoretical issues of telemedicine. During three years after this we studied the world experience of the use of telemedicine for the health care service, elaborated and implemented our own systems, evaluated the effectiveness of teleconsultations and analyzed the data. The following results were achieved: ·       we generalized for the first time theoretical bases of telemedicine; ·       clarified Ukrainian and Russian telemedical terminology  and clearly defined more than 200 terms; ·       elaborated sample schemes of formation and work of telemedical systems; ·       analyzed the effectiveness of the use of telemedicine for traumatology and orthopedics. The results of our work were described in several articles and three books. Practical realization On the 25th of January, 2000 we carried out our first teleconsultation: professor M. Nerlich from Regensburg (Germany) consulted the patient with serious pelvis trauma from Donetsk (Ukraine). Since that time we have done 144 consultations. Equipment Our telemedical workstations consist of PCs (joined as a local network), slide-scanners, digital cameras, printers, web-cameras, as well as leased Internet line (128K).  Technologies We mainly use off-line telemedical technologies: ·       e-mail (also “second opinion” teleconsultations on the patient’s request); ·       professional mailing lists (Orthopod, Orthoforum, L-Trauma, L-Ort, IndiaOrth, RussianSurginet, etc.); ·       Internet forums; ·       off-line teleconsultation servers (Intermag, etc.); ·       “Regional telemedicine system” (was created by scientific practical center “Medical computer technologies”, Barnaul, Russia); ·       ICQ. Sometimes we also carry out videoconferences, using “NetMeeting”.  In our opinion, it is important to combine off-line and on-line technologies, carrying out telemedical consultations. Indications We defined the following to indications to the use of teleconsultation: ·       necessity to diagnose and define the treatment tactics of rare, heavy and non-typical diseases; ·       necessity to carry out new or rare surgery or treatment/diagnostic procedure; ·       absence of the specialists in the given branch of medicine or the insufficient clinical experience of the doctor in treatment or diagnostics of the certain disease; ·       approval of the tactics, that has been chosen; ·       search for the alternative methods to solve the clinical problem; ·       impossibility to overcome the geographical distance between the patient and the doctor to give immediate medical help; ·       the possibility to reduce economic and financial expanses for diagnostics and treatment of the patient; ·       clarifying difficult situations (complaints, etc.), teleconsultations on request of the patient. Teleconsultations In 2000–2003 we carried out 144 teleconsultations. In 51 cases we were the inquiring party, in 88 – the consulting one, and as a mediator we worked in 5 cases. Average consultation usually takes 12–24 hours. In 99 cases the consultation was carried out by a single specialist, in 22 cases two doctors were concerned with it, in 3 cases there were three of them, and in 15 cases – from 3 to 8. In 108 cases the consultant was the candidate or doctor of medical sciences, in 17 – the professor and 1 case he was the academician.  The geography of our teleconsultations is represented in the table I. While carrying out the teleconsultations we considered 144 epicrises, 38 coloured digital clinical photos, 325 digitized X-rays, 55 computer tomograms, 103 MRTs, 4 sonograms, 7 – graphical images, 29 blocks of additional medical data (myelograms, blood tests, experts decision, EKG, biopsy data, clinical tests) and 5 cytological microphotos. In the majority of cases consultants defined the diagnoses using digital photos, digitized X-rays, computer tomograms, MRT. In 129 cases out of 144 the diagnosis was the same (in 11 cases the diagnosis was specified). In 7 cases the diagnosis of the inquirer was false (because of the lack of knowledge about this or that narrow pathology) and consultants defined the correct one. In 4 cases the consultants state the primary diagnosis. And in 4 more cases the recommendations how to diagnose the disease were given. Thus, the reliability of the diagnostics using the digital data in teleconsultations makes 72,8% according to Student criterion (p<0,05).   Table I. Geography of the teleconsultations of the Department of Telemedicine and Information Technologies of Donetsk R&D Institute of Traumatology and Orthopedics (abs.) Country Our inquirers Our consultants USA 2 9 Germany 1 10 Russia 42 83 Kazakhstan 2 1 Kyrgystan 2 1 Spain 1 1 India 17 5 Italy 2 1 Nepal 3   Ukraine 6 7 Croatia, Cyprus, Greece, Holland, SAR, Portugal, Brazil, Estonia 1 (each) – Cuba, France, Canada, Switzerland, Saudi Arabia – 1 (each) Chine, Pakistan, 2 (each) – UK, Turkey, Belgium, Venezuela – 2 (each) Israel, Namibia – 3 (each)   Distant consultations were carried out for 92 men and 52 women. The age differentiation – from 3 months to 80 years. The table II represents the quantitative characteristics of the groups of questions, which were considered by the consultants during the consultations. Table II. Quantitative characteristics of the groups of questions, which were considered during the consultations (abs.) Group of questions Quantity Diagnosing (specification or approval of the diagnosis) 15 Tactics of treatment 128 Peculiarities of surgical treatment 21 Terms of surgeries 5 Place and price (country, city, medical establishment) of treatment 13 Rehabilitation period (prognosis of function recovery; measures which should be taken to facilitate the rehabilitation, the influence of trauma on the further bone development) 8 Methods of additional examination of the patients 4 Social help 1 Evaluation of the treatment 7 As we can see from the table  3, the most common questions are those of the treatment tactics (128), as well as the questions, concerning the peculiarities and terms of the surgery (21 and 5 respectively). Thus, in the majority of cases the consultant approved of the diagnosis, suggested by the inquirer, and formulated or corrected the scheme of the treatment. Sometimes several questions were asked during one and the same session (for example, “treatment tactics and the place”, “diagnosis and tactics”, etc.). The structure of the medical spheres in which we carried out the consultations is represented in the table III. Table III. The structure of the medical spheres of teleconsultations carried out by the department of telemedicine and information technologies of D&R Institute of traumatology and orthopedics (abs., rel.) Sphere Structure Abs. Rel. % Traumatology 83 57.5 Orthopedics 31 21.5 Neurosurgery 7 4.9 Oncology 6 4.2 Hematology 3 2.1 Rheumatology and cardiology 4 2.8 Ophthalmology 2 1.4 Teratology 5 3.5 Endocrinology 1 0.7 Venereology 1 0.7 Plastic surgery 1 0.7 Total 144 100   The structure of nosologic units, considered during the teleconsultations is given in the table IV. Table IV. The structure of nosologic units, considered during the teleconsultations of the department of telemedicine and information technologies of D&R Institute of traumatology and orthopedics (abs., rel.) Nosology Quantity Abs. Rel. % 1 2 3 Polytrauma 45 31.2 Trauma of locomotorium 28 19.3 Trauma complications (contracture, false joint, vicious union, posttraumatic deformation, tissue defects) 10 6.8 Degenerative-dystrophic diseases of joints 9 6.2       1 2 3 Oncology diseases 8 5.5 In-born pathology 7 4.7 Complications of endoprosthetic repair 6 4.6 Rheumatic diseases 4 2.8 Orthopedic diseases 4 2.8 Fracture of the metal device for ostesynthesis 3 2.1 Pathologic fracture 2 1.4 Ostechondrosis, scoliosis 2 1.4 Secondary affection of the locomotorium as a result of different diseases 2 1.4 Cranial trauma 2 1.4 Osteochndropathy 2 1.4 Osteomyelitis (posttraumatic, mycosis) 2 1.4 Chondromatosis 2 1.4 Blood disease 2 1.4 Syphilitic plantar ceratosis 1 0.7 Viral cirrhosis 1 0.7 Eye trauma 1 0.7 Cheloid scars 1 0.7 Total 144 100   As we can see from the tables 3–4, the majority of teleconsulations concerns various problems of traumatology and orthopedics (main sphere of our organization), bone oncology, neurosurgery and other adjacent branches. In all the other cases we were the mediator between the inquirer and the consultant.    Our results in the use of the method of the “second opinion” consultation are also worth mentioning. There is a special web-page for the patients on our site “Telemedicine in Ukraine” and special e-mail box. 8.3% of teleconsultations were carried out using this method. The spheres of distant consultations are traumatology and orthopedics (50.0%), in-born pathology (33.4%), neurosurgery (8.3%), plastic surgery (8.3%). It expedient to mention that 50% of all the “second opinion” teleconsultations concerned traumas, acquired diseases and in-born pathologies of hand.    As it has been already said that we were the inquirers 51 times. For each question we got 1 to 8 answers (on average 2.6 replies for each clinical case), which was enough to make a final decision as for the scheme of the treatment. The suggested treatment tactics was accepted 41 times, refused in 6 cases, and in 4 cases it could nave been accepted if we had had all the necessary devices. Effectiveness of the use of the suggested treatment methods makes 80% at teleconsulting.    We carried out a research to find out whether the use of the off-line consultations is effective to treat the patients with polytrauma. The results were as follows: ·       16% reduction of the terms of in-hospital treatment; ·       9.2% reduction of the complication frequency (more than that, it is statistically proved that the structure of complications changes a lot so that the mild forms prevailed); ·       10% reduction of the relative risk of having complications; ·       0.4% reduction of re-hospitalization parameter. Conclusion Our theoretical work-outs are implemented and  successfully tested in the treatment and diagnostic work of Donetsk R&D Institute of traumatology and orthopedics. The articles and monographs, which have been published, are used as method guides in the telemedical centers of Ukraine and Russia. We have already carried out 144 teleconsultations, working with the specialists from 31 countries. The reliability of the correct diagnostics using the digitized data makes 72.8%. The effectiveness of the use of the suggested methods of treatment makes approximately 80%. The use of teleconsultations for the treatment of patients with polytrauma allows to reduce the terms of in-hospital treatment in 16%, the frequency of complications in 9.2% and relative risk of developing the complications in 10%, as well as the parameter of the re-hospitalization in 0.4%.    We recommend the widespread use of the off-line consultations on the basis of the Internet-technology.  References [1] Vladzymyrskyy A.V., Magomedov A.Yu.: Experience of using of the telemedicine in Poly-trauma Department, Travma, 2002, vol. 3, No. 1, 59–65 (rus.). – [2] Vladzymyrskyy A.V., Dorokhova E.T.: Telemedicine in Health Care Management, Medichna osvita 2002, 2, 15–17 (ukr.). – [3] Vla-dzymyrskyy A.V., Dorokhova E.T.: Ethical and deontological aspects of the telemedicine, Vestnik gigieni i epidem 2001, Vol. 5, 8–11 (rus.). – [4] Vladzymyrskyy A.V., Lyakh Yu.E., Klymovytskyy V.G.: Telemedicine: glossary, Donetsk 2001, 44 (rus.). – [5] Grigoriev A.I., Orlov O.I., Loginov V.A. et al.: Clinical Telemedicine, Moscow, “Slovo” 2001, 144 (rus.). – [6] Kazakov V.N., Klymovytskyy V.G., Vladzymyrskyy A.V.: Telemedicine, Donetsk, OOO “Nord” 2002, 100 (rus.). – [7] Lyakh Yu.E., Vladzymyrskyy A.V.: Introduction to telemedicine, Donetsk, OOO “Lebed” 1999, 102 (rus.). – [8] Yatsenko V.P.: Strategy of the telemedicine evolutuion, I International virtual scientific confe-rence “High Technologies in Telemedicine”, Donetsk 1999, 39–40 (rus.). – [9] Armstrong I., Haston W.: Medical decision support for remote general practitioners using telemedicine, J. 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To cite this article: Vladzymyrskyy A.V., Klymovytskyy V.G., Telemedicine in Ukraine, [in:] Niebrój L., Kosińska M., Unemployment and Health Care, Katowice: Wyd. SAM 2004, p. 133-139