March 24 2023
Reading time 20 minutes
The concept of telemedicine covers all medicine-related educational, information and administrative services that can be transmitted at a distance using information technology1. This includes, among other things, doctors’ councils and doctor-patient consultations by phone and video calls, via e-mail and chats. Such communication is made possible by special mobile and desktop applications2.
Telemedicine has become possible due to the general development of human civilization, innovations in telecommunication technologies that have appeared over the past 100 years, and changes in the healthcare system3.
Telecommunication technologies have been used for remote diagnosis and treatment for several decades. In Russia, the concept appeared fairly bit later than in western countries3.
The pioneers in telemedicine were doctors who consulted patients over the phone back in the era of the telegraph. For example, an 1879 article in The Lancet discussed the use of the telephone to reduce clinic visits3. In 1925, the cover of Science and Invention journal featured a doctor diagnosing a patient over the radio3.
As for videoconferencing, the first session took place in 1965 during an aortic valve replacement4. Remote monitoring originated in the Mercury space program when NASA began conducting physical examinations of astronauts3.
Telemedicine has become more widespread during the Internet age5. Scientists and medical experts have gained access to more options and more precise tools. The Internet has opened new prospects for telehealth mostly due to the following factors5:
Efficient transmission of large amounts of data over long distances. As a result, the speed and capabilities of telemedicine have dramatically increased and continue to grow to this day.
Digitization of information. This has made it much easier to send and receive, manage and store medical data.
Significant cost savings on the digital technology required to use telemedicine.
Overall the Internet has played the role of a long-awaited technological catalyst for telemedicine.
The active development of telemedicine services in Russia was initiated by Federal Law No. 242, also known as the law on telemedicine6. It entered into force on 01/01/2018 and has been further developed and supplemented for the last five years by the Ministry of Health and the Government of the Russian Federation. The most significant changes are listed in the table below.
July 29, 2017
Federal Law No. 242-FZ was adopted, regulating the provision of medical care using telemedicine technologies and the creation of a Uniform State Information System in the field of healthcare6
November 30, 2017
Order of the Ministry of Health of Russia No. 965N «On approval of the procedure for organizing and providing medical care using telemedicine technologies»7
July 22, 2020
The Federal Law «On experimental legal regimes in the field of digital innovations in the Russian Federation»9
October 30, 2020
A temporary regulation defining the rules for the use of telemedicine technologies in the treatment of patients with a confirmed diagnosis of COVID-198
September 15, 2021
Methodological recommendations of the Ministry of Health on ensuring the functionality of the centralized system (subsystem) «Telemedicine consultations»10
February 4, 2022
Letter No. 11-7/I/2-1631 of the Ministry of Health of the Russian Federation «On methodological recommendations on methods of paying for medical care at the expense of compulsory medical insurance»11
Changes in the legislation in the field of telemedicine of the Russian Federation for the period from July 2017 to February 2022
At the same time, several draft laws appeared that made it easier for patients to remotely access complex treatment, for example, introduction of an electronic prescription form12 and a law on the remote sale of medicines13 in the spring of 2020.
Payment for medical care in the format of telemedicine consultations at the expense of the public medical insurance fund are specified by the relevant methodological recommendations (joint letter of the Ministry of Health of Russia and the FFOMS dated February 4, 2022 No. 11-7/I/2-1631)11.
ФFederal Law No. 405-FZ of October 20, 2022 «On Amendments to the Federal Law – On the Circulation of Medicines» further expands the possibilities of using telemedicine14. It defines three regions: the city of Moscow, and the Moscow and Belgorod regions for approved remote retail sales of prescription medicine. The law comes into force on March 1, 2023 and will operate in an experimental format for three years.
Not all innovations were deemed viable. For example, on July 20, 2022, the Ministry of Health blocked four applications for the creation of experimental legal regimes in the field of telemedicine15. The key points leading to their denial were as follows15:
Collection and processing of depersonalized data from electronic medical records and conducting real clinical practice studies using artificial intelligence algorithms. The methods for collection and storage of information came under question. For example, the Ministry of Health did not see a single way to standardize data that could be used by all service providers.
Transfer of a patient with an in-site diagnosis to remote monitoring by a third-party medical organization. The Ministry of Health believes that the patients should be monitored remotely in the same clinic which they attended in person.
Allowing a preliminary diagnosis and prescribing symptomatic treatment through an online consultation. It is still unacceptable to make a diagnosis without a personal appointment in accordance with the main law on telemedicine No. 242-FZ6.
The level of development of telemedicine in Russia allows doctors from large cities to provide highly specialized care to patients from remote regions who are not able to come to an appointment in person.
The methodological recommendations10 of the Ministry of Health provide for the possibility of remote interaction in various situations:
Urgently – in case of exacerbation of chronic diseases and in case of sudden acute diseases and conditions that pose a serious threat to life.
In an emergency form – for diseases and conditions without obvious signs of a threat to the patient’s life.
Scheduled – in situations that do not require emergency and urgent medical intervention. In other words, when a delay in medical care does not pose a threat to life and health and cannot lead to a deterioration of the condition.
Since 2020, telemedicine consultations on an outpatient basis have been carried out as part of the Russian compulsory health insurance program (OMS). The service falls under the per capita funding standard10. For inpatient treatment, telemedicine consultations are included in the cost of a completed treatment case, calculated on the basis of statistical or profile-based clinical groups of diseases10.
Other cases: it is allowed to establish fees for paying for remote medical care for private clinics that are registered in the public health insurance register10. It is also possible to apply for an expert opinion in medical institutions located in other regions, including the reference center in the capital16.
Medical workers of various levels can also interact remotely. If one needs to conduct a remote consultation or a doctors’ council using telemedicine technologies, the algorithm will be as follows10:
An appropriate request is formed.
Invitations are sent out.
The consultation is held.
Based on the results, a protocol is drawn up and signed.
The Russian Ministry of Health has developed scenarios for conducting telemedicine consultations in emergency (with a threat to life) and urgent (without a clear threat to life) situations. An algorithm is prescribed for remote monitoring of the patient’s condition, as well as for making a conclusion based on the results of diagnostic studies10.
Telemedicine is also used as information support for specialized training processes for medical specialists10.
Telemedicine services in the commercial sector deserve special attention. They fall under the category of planned assistance110.
Telemedicine is suitable for everyone, but it is especially useful for patients who2:
live in remote and hard-to-reach settlements, far from the doctors with a narrow specialization;
have movement, time or transport limitations;
need urgent medical attention while away from home (on vacation or business trip).
The list of remote medical services approved by the Ministry of Health of the Russian Federation includes10:
Online consultation or online appointment (doctor-patient). A patient can communicate with doctors via video and audio, as well as through a chat. This may be a pre-arranged half-hour visit, keeping in touch throughout the day or other option accepted by the medical organization for real-time meetings or scheduled consultations7.
Remote health monitoring (doctor-patient). Monitoring of the patient and their health can be carried out online, but strictly following the results of a in-site consultation and with a confirmed diagnosis7.
Second opinion and specialized training (doctor-doctor). The practice of obtaining an additional opinion from a medical specialist, such as clarifying a diagnosis and treatment plan based on the results of a medical examination. It is carried out in the form of interdisciplinary consultations of doctors and councils. In addition, other formats are used: mentoring and monitoring, training of nursing staff, holding administrative meetings and additional training7.
Due to the development of remote technologies, online personal appointments or diagnostics have become much more efficient7. For example, a therapist may quickly refer the patient to mandatory tests or to the right specialist for examination and diagnosis.
Another advantage of telemedicine services is the management of information, such as analysis or examination results, doctors’ conclusions, health indicators, personal recommendations for each patient7. Collection, storage and documentation of information in clinics and laboratories have become more efficient with the advent of telemedicine applications.
In addition, from 2020 medicines and dietary supplements can be sold in online pharmacies17, and from 2021 on online marketplaces18. These innovations are also a consequence of the growth and development of telemedicine.
There are significant differences between an online consultation handled under the compulsory medical insurance system and a private telemedicine appointment.
For patients undergoing treatment in in-patient hospitals and clinics, the following procedure for conducting telemedicine consultations10 applies:
The decision on the need for a consultation is made by a medical worker (the attending physician, paramedic, resuscitation specialist) by creating a referral, indicating the type and mode for the consultations or council.
A draft referral for a consultation is formed in the telemedicine system of remote consultations at the federal and regional levels19. The system automatically or manually finds a suitable medical organization and determines the availability of time for a particular consulting specialist.
The patient’s clinical data are entered into the system, which can be supplemented at the request of the consulting party.
The time of the consultation is booked.
The head of the department or the head of the medical institution approves and signs the referral for a consultation.
The consulting party receives an invitation to a consultation and access to patient data, after which they confirm their participation.
Consultation within the telemedicine system works as an interaction of participants, each a representative of a medical institution. It usually takes place via videoconference.
The consulting doctor or members of the council sign the final protocol.
An online appointment using one of the private telemedicine services is usually carried out as follows2:
The decision to teleconsult can be made by the patient, or the consultation is carried out as part of a previously planned treatment plan.
The doctor is in the clinic, located in his office, equipped with a computer, video camera and headphones with a microphone. The patient can be located anywhere: tens of kilometers from the clinic or even on the other side of the globe. Instead of a computer, they can use a smartphone.
In some cases, patients are asked to pay in advance the full or partial cost of the appointment and share the necessary information – for example, fill out a questionnaire, list symptoms and past appointments in a chat, upload documents (laboratory results or preliminary diagnosis). This way the doctor can better prepare for the consultation.
During the online appointment, the doctor asks the same questions as in a traditional appointment learning about complaints and the purpose of the visit, and collects an anamnesis.
Depending on the information collected, the specialist prescribes laboratory tests or refers to other doctors.
In Russia, it is forbidden to make a diagnosis via the Internet: this is prohibited by the law on telemedicine No. 242-FZ6. A physical examination is always necessary. Primary remote consultations are informational in nature and are needed to collect and analyze complaints, as well as to make a decision on the need for an in-site appointment. Primum non noncere (lat. first, do no harm) is a well-known principle in medicine.
Such an appointment can provide the patient with preliminary information, prescribe the necessary tests and examinations, discuss their results with a doctor at home and get a referral to another specialist.
Telemedicine services have proven to be especially beneficial during the pandemic. Below are some strengths of the system, relevant in the current day.
Expanding access to medical care. Telemedicine helps overcoming physical barriers to health care, especially when visiting doctors of a narrow profile. This can help out patients located in areas with insufficient medical equipment, where there are not enough specialists22.
Saving time for both the patient and the doctor. During an online appointment, the patient does not need to explain who he is, what was his issue and when he was in the clinic. All information is available to the administrator at the time of registration, and to the doctor at the stage of admission. The doctor knows exactly when and what time the remote consultation will take place, and does not waste his personal time communicating in the messenger and responding by e-mail.
Comfort and convenience of being at home. Virtual visits are easier to fit into a busy life schedule20. Adult working people can visit a doctor right at the workplace: they do not need to take time off. Immobile patients or children can be connected from home.
Protection against hospital infections. Telemedicine eliminates the need to come to the hospital and stand in line for minor issues20. This reduces contact with viruses and bacteria, which is especially important for children, the chronically ill, pregnant women, the elderly or people with weakened immune systems.
Rapid primary care when a visit to the clinic is not required. Telemedicine makes it easy to contact a therapist within his schedule and find out in advance the list of required tests, as well as get a referral to a personal appointment with a narrow specialist20.
Assessing the prospects for public and commercial use of telemedicine technologies should be differentiated. As part of the digital transformation strategy for the Russian healthcare industry for the period up to 2030, the state has outlined the challenges and problems that are to be addressed in the field of telemedicine. The primary tasks include23:
Creation of digital services for healthcare workers and patients.
Providing individual guidance to the insured in the provision of medical care.
Providing health monitoring of patients with chronic diseases using digital technologies.
At the end of 2022, a pilot project was launched to remotely monitor the health of patients using high-tech devices and services, the so-called personal medical assistants24. Two hundred patients with hypertension and diabetes received automated diagnostic devices which transmitted information to a digital platform in real time for further processing and feedback from doctors. The pilot project will last two years. By the end of 2024, it is planned to perfect the process of automatic collection and analysis of data and the associated platforms, devices, and technologies24.
One such technology is a symptom checker that is embedded in portals or medical information systems. The technology works according to the following principle:
The patient receives an SMS or push notification with a link to the application, Telegram bot or online form, where he answers questions about symptoms and medical history.
Artificial intelligence trained on medical texts suggests three possible diagnoses based on the collected data.
Before the appointment, the doctor studies the anamnesis and assumptions made by the AI. The last word in the diagnosis remains with the specialist.
The symptom checker allows to get a preview of the patient’s health in advance and thus save up to 30% of the time of the appointment, which can be spent on a more detailed examination, diagnosis and referrals.
The next stumbling block for commercial telemedicine is the issue of remote diagnosis, which, if properly solved, can give a strong impetus to market growth. Everybody is looking forward to such solution, but for now the Russian Ministry of Health adheres to law No. 242-FZ and believes that without a physical examination of the patient, the probability of error is too high15.
The risks are largely due to the limitations of current technical equipment15:
the chance for distortion of received and transmitted information is too high;
it is difficult to control the quality of medical services;
there are issues connected to identification of doctors and patients;
payment and taxation systems for medical services have not been properly developed.
Legal risks include disclosure of medical confidentiality and violation of the confidentiality of personal data.
The situation was succinctly described by the President of the Russian Federation, speaking on July 22, 2022 at the plenary meeting of the Agency for Strategic Initiatives. Emphasizing that telemedicine will undoubtedly develop, he noted that it is necessary to act carefully and gradually in order to avoid causing any harm: «…so that we won’t end up as in that famous story:
– Doctor, you pulled out a healthy tooth!
– Not a problem! We’ll eventually get to the sick one!»21.
Thus, the issue of expanding the capabilities of telemedicine has already gone beyond the competence of the Ministry of Health and will be addressed at the highest level.
The information in this article is current as of January 2023.
Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine; Field MJ, editor. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington (DC): National Academies Press (US); 1996. 1, Introduction and Background. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45440/.
How Does Telemedicine Work? [Online resource]: WebMD. URL:https://www.webmd.com/covid/how-does-telemedicine-work.
Board on Health Care Services; Institute of Medicine. The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington (DC): National Academies Press (US); 2012 Nov 20. 3, The Evolution of Telehealth: Where Have We Been and Where Are We Going? Available from: https://www.ncbi.nlm.nih.gov/books/NBK207141/
The History of Telehealth: Telemedicine Through the Years. [Online resource]: Sigmund Software. URL: https://www.sigmundsoftware.com/blog/history-of-telehealth/
Federal Law of July 29, 2017 No. 242-FZ. [Online resource]: Website of the Government of Russia. URL: http://government.ru/docs/all/112731/
Order of the Ministry of Health of Russia No. 965N “On approval of the procedure for organizing and providing medical care using telemedicine technologies”. [Online resource]: consultant.ru. URL: https://minjust.consultant.ru/documents/38004
Temporary regulations defining the rules for the use of telemedicine technologies in the treatment of patients with a confirmed diagnosis of COVID-19.[Online resource]: consultant.ru. URL: http://www.consultant.ru/document/cons_doc_LAW_348101/5284cfe3d3845d754c4e0bcca0e8b26c21cc12bc/
Federal Law “On Experimental Legal Regimes in the Sphere of Digital Innovations in the Russian Federation”. [Online resource]: Official Internet portal of legal informationURL: http://publication.pravo.gov.ru/Document/View/0001202007310024
Methodological recommendations of the Ministry of Health on ensuring the functionality of the centralized system (subsystem) “Telemedicine consultations”. [Online resource]: Russian Ministry of Health. URL: https://portal.egisz.rosminzdrav.ru/files/МР%20ТМК_v1%20(1).pdf
Letter of the Ministry of Health of Russia N 11-7 / I / 2-1631 “On methodological recommendations on how to pay for medical care at the expense of compulsory medical insurance.”[Online resource]: Moscow City Compulsory Medical Insurance Fund URL: https://www.mgfoms.ru/document/160
Vladimir Putin supported United Russia’s initiatives on the remote sale of prescription medicine and the ability to remotely issue electronic prescriptions. [Online resource]: United Russia.URL: https://er.ru/activity/news/vladimir-putin-podderzhal-iniciativy-edinoj-rossii-o-distancionnoj-prodazhe-recepturnyh-lekarstv-i-vozmozhnosti-distancionno-vypisyvat-elektronnye-recepty
Federal Law No. 105-FZ dated April 3, 2020. [Online resource]: Official Internet portal of legal information.URL: http://publication.pravo.gov.ru/Document/View/0001202004030060
Federal Law of October 20, 2022 N 405-FZ “On Amendments to the Federal Law on the Circulation of Medicines”. [Online resource]: Rossiiskaya Gazeta.URL: https://rg.ru/documents/2022/10/23/document-1666538323308218.html
Telemedicine did not find support from the Ministry of Health. [Online resource]: Vedomosti.URL: https://www.vedomosti.ru/technology/articles/2022/07/20/932329-telemeditsina-podderzhki
Moscow Reference Center for Radiation Diagnostics. [Online resource]: Center for Diagnostics and Telemedicine.URL: https://tele-med.ai/proekty/moskovskij-referens-centr_new
The State Duma adopted in the third reading a draft law on the online sale of OTC medicine. Online resource: vc.ru.URL: https://vc.ru/legal/113450-gosduma-prinyala-v-tretem-chtenii-zakonoproekt-ob-onlayn-torgovle-bezrecepturnymi-lekarstvami
The government allowed the online sale of OTC medicine through online marketplaces. Online resource: vc.ru.URL: https://vc.ru/trade/253350-pravitelstvo-razreshilo-onlayn-torgovlyu-bezrecepturnymi-lekarstvami-cherez-marketpleysy
TELEMEDICINE SYSTEM OF REMOTE CONSULTATIONS OF THE FEDERAL AND REGIONAL LEVELS.Online resource. URL: http://tmk.minzdrav.gov.ru/Account/Login?ReturnUrl=%2f
Benefits of Telemedicine. Online resource: Johns Hopkins Medicine. URL: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/benefits-of-telemedicine
Constructive proposals will receive support: Vladimir Putin spoke at the plenary session of the Strong Ideas for the New Times forum. Online resource: asi.ru.URL: https://asi.ru/news/189629/
Advantages of Telemedicine. Online resource: Doxy.me. URL: https://doxy.me/en/advantages-of-telemedicine/
Digital Transformation Strategy for the Healthcare Industry. Online resource: Russian Ministry of Health.URL: https://static-0.minzdrav.gov.ru/system/attachments/attaches/000/057/382/original/%D0%A1%D1%82%D1%80%D0%B0%D1%82%D0%B5%D0%B3%D0%B8%D1%8F_%D1%86%D0%B8%D1%84%D1%80%D0%BE%D0%B2%D0%BE%D0%B9_%D1%82%D1%80%D0%B0%D0%BD%D1%81%D1%84%D0%BE%D1%80%D0%BC%D0%B0%D1%86%D0%B8%D0%B8_%D0%BE%D1%82%D1%80%D0%B0%D1%81%D0%BB%D0%B8_%D0%97%D0%B4%D1%80%D0%B0%D0%B2%D0%BE%D0%BE%D1%85%D1%80%D0%B0%D0%BD%D0%B5%D0%BD%D0%B8%D0%B5.pdf?1626341177
A pilot project was launched in Russia to remotely monitor the health of patients using high-tech devices and services. URL:https://minzdrav.gov.ru/news/2022/12/29/19716-v-rossii-startoval-pilotnyy-proekt-po-distantsionnomu-monitoringu-sostoyaniya-zdorovya-patsientov-s-ispolzovaniem-vysokotehnologichnyh-ustroystv-i-servisov
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