Telematics Solutions for the Health Care Sector:
"Move the information, not the patient"

1. Introduction: What is Telemedicine in General and in Developing Countries?
2. Telemedicine Market: Analysis of the History
3. Uzbekistan Peculiarities: Population, Health Status and Health System
4. Pilot Telemedicine Projects in Uzbekistan: First Steps
5. Conclusion

Introduction

Telemedicine is the transfer of medical expertise through telecommunications networks from any distance and also its use wherever and whenever the patient is located. The benefits that can be achieved are numerous. The general level as well as the accessibility of health care services improve significantly using telemedicine; and, the equality between rural areas and urban centres increases. An immediate benefit is the decrease of patient transfers through an efficient use of modern telecommunications solutions. The role of basic health care becomes much more significant when specialized health care resources can be used optimally. Quicker diagnoses and health care enhancements bring savings to many parties and improve patient safety and care. Telemedicine also provides new and interesting business opportunities to the private sector without geographical limitations.

Besides telediagnostic applications, telemedicine has open care, remote monitoring and administrative applications as well. The efficient use of medical data bases and information resources, e.g. through the Internet is also one of the major aims of telemedicine.

Telediagnostics

Imaging and image information is essential in diagnostics. Telediagnostics focuses on developmental work related to radiology, pathology and histology as well as dermatology. For example, sound can be easily transmitted as a normal computer file to request the statement of a cardiologist about abnormal heartbeats or heart murmurs.

Teleradiology

Teleradiology is currently the most important application field in telemedicine internationally. The situation in Finland is particularly unusual. There is X-ray equipment in almost every health care centre, but the radiologists are only located in large hospitals. This emphasizes the importance of teleradiology. Specialized nurses in the radiology department of a health care centre can make X-rays, digitalize X-ray films with a special scanner and transfer them to an appropriate service provider, which can be either a university or a private hospital. Nurses and general practitioners can also perform ultra-sound examinations with the remote guidance of a radiologist. Teleradiology also provides excellent diagnostics capabilities between hospitals, e.g. for CT and MRI, especially in the field of neurophysiology.

Teledermatology

Videoconferencing systems and high resolution cameras provide the means to transmit close-up, still-pictures during real-time consultations. This has turned out to be an ideal solution for general practitioners of health care centres who need dermatological consultations. Digital cameras are another good alternative to be considered, but the size of the still image file is quite large and requires fast connections.

Teleconsultations

A videoconferencing system has many functions. Unnecessary travelling of the patient can be avoided when doctors use videoconferencing to consult specialists. The visual aspect is important when one physician is consulting another. It is possible to perform at the various remotely-guided medical acts and examinations using one videoconferencing system, with additional features. The system also enables an exchange of information including texts, diagramms or pictures.

Remote guidance and training

Multi-point videoconference seminars can be organized to respond to the educational needs of the general practitioners working in remote health care centres. District-wide training seminars can be held without losing too much of the physicians working time because travelling can be reduced or eliminated. Internet-based training options will be used in the near future.

Laboratory information

Laboratory results are much more easily available and transferrable when they are computer files. Several systems have been developed and can be used with data transmision networks so that results can be conveniently transmitted between health care sites, which can lead to faster treatment decisions.

Telecardiology

ECGs are transferred to cardiologists or emergency centres using network connections like GSM. Also, heart murmurs can be transmitted to cardiologists who can then evaluate the condition of the patient.

Telepsychiatry

Real-time videoconferencing consultations between physicians of health care centres and psychiatric experts make their work more efficient and enhance the use of available resources. The experiences in other countries in this field, e.g. in infantile psychiatry, have reinforced the usability of telepsychiatry in health care.

Tele-endoscopies

Quite often, gastroscopies and otoscopies have been performed locally and diagnoses have been made hundreds of kilometers away. Videoconferencing systems with additional features are quite well suited for these procedures. Local physicians skills and expertise improve under specialists guidance.

Teleneurophysiology

The real-time transfer of EEGs through telecommunications networks has been problematic due to the large amount of data it involves. The new high-speed ATM networks are an adequate solution thereby making more efficient of the neurophysiological resources of the large medical units nationwide. For examle, CT and MRI brain image files can be transferred almost instantaneously between two hospitals, again, making treatment faster.

Telepathology

Telepathology is mainly aimed at hospitals. During a surgery, it is possible to take a frozen section and transmit the image through videoconferencing connection to the pathologist of a central hospital. The pathologist can get still-images from the live picture when necessary and give a diagnosis and advice regarding the continuation of the surgery. Also, high resolution still-pictures taken with digital cameras can be transmitted as ordinary files to pathologists for statements in less urgent cases.

What is telemedicine status and current development in developing countries? One can find depth analysis of this problem in [1].

Telemedicine Market: Analysis of the History

Our analysis based on two surveys findings which were conducted in 1995,1997 years by D.R.Dakins[2], and some publications.

First survey of 296 telemedicine and teleradiology program managers paints revealing picture of the state of telemedicine in 1997 in the U.S. Key fundings from this survey include:

• Teleradiology, telecardiology, teledermatology, psychiatry, and emergency medicine are the top clinical applications in use at telemedicine sites;
• Filling a specialty access need is the number-one reason hospitals embark on telemedicine services, followed by the need to use staff resources more efficiently;
• More sites are investing their own funds in telemedicine equipment and services instead of relying on grant funding;
• Interactive video is a major component of telemedicine services, but use of the Internet for store-and-forward image and video transmission, patient records, and patient consulting is on the rise;
• Most programs do not measure the success of their telemedicine efforts, but among those that do, cost savings and better patient outcomes are important indicators of success;
• An overwhelming majority of managers believe their telemedicine and teleradiology services are underutilized;
• Physician acceptance is the primary challenge telemedicine programs face, closely followed by equipment functionality.

It is not suprise that teleradiology is the most popular clinical applications. The market in 1997 is not saturates, particularly in terms of outreach in rural regions, where radiology specialists are few. This means increasing opportunity for teleradiology service providers to contract with outlying hospitals for primary diagnosis and overrides.

Telemedicine-mediated cardiology is provided at 46% sites, followed by dermatology (44%), psychiatry (43.5%), energy medicine (39.8%), home healthcare (23.1%), pathology (21.3%), and oncology (20.4%). This only slightly from a casual review of applications in use at sites in 1995, which ranked radiology, dermatology, cardiology, psychiatry, and emergence medicine in the top spots.

Interactive video is in use at 72% of sites providing clinical telemedicine services. Despite healthcare industry trends toward multimedia messaging, telemedicine managers find interactive video useful in numerous clinical applications.

At the same time, the Internet is emerging as a tool in telemedicine service delivery, primarily of the store-and-forward variety. About 10% (31) of total sample of 296 program managers indicated that they use the Internet for a number of purposes, including medical image transfer (74.2%), patient-care consulting (51.6%), patient records (41.9%), and video transfer (38.7%). The latter statistic is a key indicator of advances in high-speed networking and desktop video and how they are being integrated with healthcare networks.

What were telemedicine market drivers in 1997?

When taken in the context of the top clinical applications, it is clear that access to and efficient delivery of radiology, cardiology, dermatology, psychiatry, emergency medicine, and home healthcare are not being addressed by traditional healthcare approaches. Implementers are therefore looking to telemedicine as a solution to these problems. In addition, the fact that these applications have remained near the top for more than two years may indicate the continued potential of these markets, particularly in cardiac and home healthcare.

Other motivations cited illustrate the growing maturity of telemedicine. Telemedicine implementers were seeing the service as away to increase operational efficiency trough better use of staff resources (18.3%), provide rapid information transfer (13.3%), achieve better physician collaboration (12.2%), compete in managed-care climates(11.3%), and provide medical education (7.8%).

Drivers like these portend well for enterprise-wide integrated networks. The rise of Internet use for telemedicine applications, it is interesting to note motivations such as rapid information transfer and better physician collaboration. The fact that telemedicine seen as competitive advantage in managed-care climates is but one indication that the service has potential as an efficiency tool.

Maturation of the telemedicine market is revealed by yet another survey funding:52% of sites are investing their own funds to provide these services.

What are markers for success?

Among programs that do measure success, the primary modes of measurement are assessment of cost savings (23%) and better patient outcomes (23%). Other measures of success include staff efficiencies (11.4%), which ties into one of the primary motivations for starting of telemedicine service.

But evidence of telemedicine as a business strategy can be seen in two other measures cited: larger market share (6.1%), and increased revenues (1.8%). Although the latter percentage is small, it is a key market indicator, in that it reveals the changing perception of telemedicine as a potential revenue generator or instead of a loss-leader.

Two critical signposts regarding the state of telemedicine in 1997 are found Managers cited lack of physician and staff acceptance as primary operational challenge. But in close second to user acceptance, managers rated equipment functionality as a major operational problem. Lack of adequate funding (36.9%), and staff (35%) follow on the list of problems, along with lack of training (29%).

While scheduling telemedicine consults is often cited as particularly challenging, this operational problem lagged behind those cited above, at 23%. And although many researches have focused on acceptance of telemedicine by patients, only 1.8% of sites noted that this aspect has caused problem.

In 2000 TIE interviewed Dr.F.Fields of Feed Back Research Services (USA); latter is a leader in the production of timely market analysis reports for telemedicine and health care [3]

Was put the question about any trends in funding telemedicine/telehealth (in terms either of funding amounts, or funding priorities e.g., research, clinical care provision, subsidized care (versus short-term grant funding)). One of the reason that the teemedicine "market" seems so robust is the huge amount of funding that has been allocated by federal and state sources. Military expenditures have historically been among the largest and many grants have been issued to telemedicine program by different agencies. This efforts represent hundreds of millions dollars, but only a relatively small portion involves equipment purchases. Therefore, analysis of funding sources doesn't provide with useful information about size of telemedicine market.

What effect will e-health and the growth of the Internet have on telemedicine?

In 2000 year it's become clear that the advertising/ sponsorship business model for health information portals would not be sufficient. Other revenue sources will need to be developed and e-commerce seems like a reasonable route to take. Despite ongoing issues with confidentiality, consent, privacy, and regulation, there are examples of successful transition of traditional medical services to the Internet,such as online pharmacies. As doctors become more comfortable with new ways of delivering health care, the Internet also offers novel marketing and patient-physician relationship opportunities.

Until broadband access becomes widespread within U.S. households, however, the Internet is likely to only support e-mail and informational activities, rather than videoconferencing-based interactions such as telemedicine. This may be the case for another two or three years. In the meantime, there is increased interest from consumers to obtain free, reliable health care information. This creates a potentially huge new audience for provider organizations (such as the Mayo Clinic) that can extend an existing reputation for high-quality medical services. When a person's physical location becomes less of an issue, new delivery systems such as telemedicine could allow these Web site visitors to become patients. In another scenario that is already happening to a certain extent, health care providers are able to use the Internet to monitor chronically ill patients to identify and alleviate problems before a more serious situation occurs. Ultimately, information access (appointment scheduling, ask-the-doctor forums, medical research, nurse advice, etc.) will be combined with medical services in a unique way, perhaps within the next five years. The Application Service Provider (ASP) model is likely to be especially important for this to happen quickly.

Jeffrey C.Bauer in 2001 [4] considered that the depth and breadth of telemedicine grew much faster over the past few years than the government's ability to give it an industrial classification and measure it as a business sector. Consequently, economic estimates based on government reports fail to capture the full size of the market. Some polling organizations have attempted to develop more inclusive estimates, but their efforts have also suffered from the lack of an up-to-date definition of telemedicine. The solution might seem to be development of an inclusive measure of telemedicine, but it is doubt this task can be accomplished in a meaningful way. The scope of telemedicine will continue to grow faster than our ability to measure it. In addition, the true measure of telemedicine should also include the value of expenditures on telecommunications, human capital, and other resources consumed in the process of delivering health care over the barriers of time and distance. We are probably doomed to underestimates based on numbers that flow Interest in telemedicine must be growing. In spite of the well publicized crash in markets for high-tech stocks, people with money still seem interested in possibilities for financing companies in the business of telemedicine. It is difficult to give the facts of telemedicine market size and its projects growth. The problem begins with the historic definition of telemedicine. Until recently, telemedicine was defined as interactive video systems that linked rural patients with urban specialists.

It required bulky television equipment with cameras and monitors at both ends of a real-time encounter. Due to the high expense of this technology and related telecommunications bandwidth, - fiberoptic cable or bundled telephone lines - most telemedicine was funded by federal grants. The total amount of these grants was often used as an economic measure of the size of the market for telemedicine. Figures commonly added an estimate of spending on teleradiology, the other widespread application of telemedicine. However, telemedicine began to expand in very different directions in the late 1990s. The concurrent development of digital diagnostic peripherals (e.g., electronic stethoscopes, digital cameras, vital signs monitors) and through federal agencies. Accuracy of survey-based estimates has been cast in doubt for a variety of methodological reasons. Initially, almost any estimate of the size of the telemedicine business should be interpreted with a big grain of salt. Customized models need to be created to provide meaningful estimates reflecting the evolution of technology for a specific application of telemedicine. Market growth over time, separate from market size at a point in time, is equally hard to predict with an acceptable level of confidence. The time lag between data collection and data reporting is almost always a year or two. The definition of telemedicine is expanding at a much faster rate, exacerbating the problem of underestimates. Telemedicine is a moving target, one that is very difficult to measure. The good news is that the market is obviously growing. One proxy measure, the number of trade show exhibitors at the annual meeting of the American Telemedicine Association, is doubling every year. An accelerating number of telemedicine applications reported in published literature is also evident to anyone who reads it. Creative physicians,nurses, and health systems are constantly finding new ways to deliver medical care over the Internet. Last but not least, reimbursement for telemedicine is becoming relatively common. Many health plans now pay for telemedical services, and a complete set of CPT codes for telemedicine has recently been published. These are signs of growth, not stagnation or decline. Although these signs lead to conclude that the telemedicine business is big and getting bigger, some commentators advance the recent demise of so many "dot-coms" as evidence to the contrary. This position confuses the stock market with the business itself. Sure, lots of health technology companies are now worth a few pennies on the dollar of their 1999 or 2000 market valuations, but many had developed sustainable technologies that are being bought by investors who know how to manage for longterm value - something very different than managing for short-term capital gains and stock options.

Uzbekistan Peculiarities: Population, Economy, Health Status, Health System

Uzbekistan [5] lies in the middle of Central Asia,between the two major rivers Amu-Darya and Syr-Darya. It borders Kazakhstan to the north,Kyrgyzstan and Tajikistan to the east, Afghanistan to the south and Turkmenistan to the west. The population density is approximately 54 people per km². The Republic of Uzbekistan consists of the autonomous republic of Karakalpakstan and 12 provinces (oblasts). Uzbekistan has 121 cities, of which 55 are of national significance, as well as 113 urban settlements and 163 rural districts. Tashkent, the capital, has a population of 2.3 million (Ministry of Macro-Economic Statistics, 1999).

Basic data on Uzbekistan and the WHO European Region
	Uzbekistan (1998)	Europe (1997)
Population (millions)	24,0
Population aged 0-14 years, %	39,4	20,1
15-64 years, %	56,4	66,3
>= 65 years, %	4,2	13,6
Area, km2 Population density per km2	447 400 53,6	31
Urban population (%)	37,9	72,7
Births per 1000 population	23,1	11,11
Deaths per 1000 population	5,9	10,94
Natural growth rate per 1000 population	17,2	0,17
Gross domestic product (GDP) per person in US$, PPP*	2670	12500
*PPP-purchasing power parity

Economy

Owing to the implementation of a programme of privatization a multi-layered economy has developed, in which the private sector is playing an increasingly important role. It accounts for some 70% of the country's GDP, 64% of industrial output, 99% of foreign currency agricultural output and more than 70% of construction work. Uzbekistan is rich in natural resources. The country has almost 74% of the central Asian region's total deposits of natural gas, 81% of its oil and 55% of its coal. The country's natural gas output places it third among the republics of the former USSR and tenth in the world. Structural changes in industry in the years before independence were primarily aimed at ensuring the country's self-sufficiency in energy and manufacturing. Development was accelerated in the fuel and energy sectors and in metallurgy and automobile manufacturing. A process of deepening reform is continuing in agriculture. Work is being done on transforming agricultural enterprises and creating a class of landowners. Production of cereals, meat, milk and eggs has increased. The scope of retail trade is increasing, as is the proportion of the population who are economically active.

According to official data, the unemployment rate in 1997 was 0.4%, which is substantially lower than the averages for the CAR and the European Region is a whole. Taking account of hidden unemployment, however, this figure is close to 5% (WHO Liaison Office in Uzbekistan, 1999). GDP growth reached 5.2% in 1997, outstripping the trend in population growth for the first time. According to available data, per capita income in Uzbekistan is roughly equal to the CAR average. The inflation rate remains high compared with developed western European countries.

Health Status

Uzbekistan has not been marked by the trends in life expectancy and mortality that are characteristic of the majority of the NIS. The steady increase in life expectancy at the end of the 1980s was replaced by a sharp fall in the first half of the 1990s. This was halted in 1994, and an upturn was seen in 1995. However, there are still high levels of mortality from cardiovascular infectious and parasitic and respiratory diseases. As in most other NIS, the incidence of tuberculosis and sexually transmitted infections is increasing.

Main causes of death and disease

As in most other countries, cardiovascular diseases (CVD) are the leading cause of death, both in people up to 65 years and in older age groups. The share of under-65 mortality attributable to CVD, diseases of the respiratory and digestive systems, and infectious and parasitic diseases is higher than the European average, whereas that due to cancer is lower. These differences are even more marked when compared with the averages for western European countries alone.

Cardiovascular diseases

The trend in premature mortality due to CVD, like that of total mortality, is distinguished by a less marked rise than the average for the CAR. Nonetheless, this increase has been very substantial and, according to available data, CVD mortality in Uzbekistan remains one of the highest in WHO's European Region. The increase in CVD mortality in Uzbekistan up to 1994 was mainly due to ischaemic heart disease and other diseases of the circulatory system. At the same time, mortality due to cerebrovascular diseases remained virtually stable, but then increased sharply in 1994; it has subsequently declined slowly. To some extent, this may be due to changes in the practice of coding causes of death.

Mental

The incidence of mental disorders has been almost stable for a number of years, at around 130-140 per 100 000 population. The incidence of disorders related to abuse of narcotic substances and that of alcoholic psychoses are substantially lower than in most other NIS. Mortality due to infectious diseases stabilized from the start of the 1990s, after a significant fall in the second half of the 1980s. Unlike the other CAR, there has been virtually no increase in this indicator in Uzbekistan. As a result, the latest data show that infectious disease mortality in Uzbekistan is lower than in the other CAR, although it is higher than in other countries of the Region.

Selected health indicators in Uzbekistan and the European Region
	Uzbekistan (1998)	Europe (1997)
Life expectancy	68,7	73,3
Men	66,1	69,2
Women	71,2	77,4
Infant mortality per 1000 live birth	22,3	12,0
Maternal mortality per 1000 live birth	8,7	19,4
Standardized death rate (SDR) for all causes of death per 100000 population	1236,2	980,1
SDR for cardiovascular diseases per 100000 population	782,5	482,7
SDR for malignant neoplasms per 100000 population	86,7	184,6
SDR for injuries and poisoning per 100000 population	53,5	86,4
SDR for diseases of the respiratory organs per 100000 population	110,7	63,5
SDR for diseases of the digestive system per 100000 population	64,4	39,1
SDR for infectious and parasitic diseases per 100000 population	28,6	13,8a
New cases of tuberculosis per 100000 population	58,3	39,8a
New cases of syphilis per 100000 population	44,9	74,0a
New cases of malaria per 100000 population	0,02	1,94a
a1998

Health Care System

Targeted reforms of the health care system have been under way in the country for a number of years. In line with the decree issued by the President of the Republic, a government programme was adopted in 1998 on reform of the health care system during the period up to 2006. The main thrusts of health system reform in Uzbekistan are to: organize maternal and child health care; improve and develop primary health care; monitor and prevent infectious diseases; and advocate healthy lifestyles (WHO Liaison Office in Uzbekistan, 1999).

Health care expenditure and health systems funding

In 1998, health care expenditure in Uzbekistan amounted to 3.3% of the GDP. This is higher than the average for the CAR, but lower than the figure for Europe as a whole. Local health care establishments are primarily funded from local budgets. The extensive devel opment of inpatient facilities has been halted, and the budget for inpatient services has been cut down to 60% of the total resources envisaged for health care, while funding for the outpatient service has been increased to 40%. The country currently has a number of private health care establishments, where some 1 million patients are treated each year. More than 2000 physicians have been licensed for individual practice. The pharmacy service has been decentralized. In 1997, the private sector delivered some 10% all medical services. The limited financial resources available to the state health care system currently dictate the need to seek additional sources of financing.

Outpatient services

According to data from the Ministry of Health, the number of outpatient/polyclinic establishments increased from 3027 in 1991 to 4074 in 1997. Arrangements for delivering medical care to patients on a day inpatient basis are currently functioning effectively throughout the country. This has reduced the number of patients treated in 24-hour inpatient facilities from 5.1 million to 3.8 million, while the number of those treated in day inpatient units has increased to 2.4 million. The development of outpatient surgical centres has changed the relationship between the numbers of operations carried out in inpatient and outpatient facilities. At present, 55% of operations are done in outpatient settings, including 23% in outpatient surgical centres. The Council of Minister's decree no. 182 of 21 May 1996 on "A programme for development of the social infrastructure in villages" provides for the organization of rural medical posts (RMPs), together with the introduction of general medical practice. In 1996-1997, 255 RMPs were built and 404 were created by transforming rural district hospitals, rural medical outpatient facilities and feldsher/midwife posts.

Inpatient services

The hospital bed rate in Uzbekistan in 1997 was lower than the average for the Region as a whole. This is a result of the policy on reform of inpatient care in Uzbekistan. Between 1991 and 1997, more than 46% of all hospital beds (i.e. those that were not being used in a rational way) were closed. The hospital admission rate fell from 24.4 per 100 population per year in 1991 to 16.3 in 1997, a figure that was lower than the average for the European Region.

The average length of stay in hospital also fell from 14.9 days to 13.5 days: this decline was not so significant, however, and the indicator remains higher than the European average.

Medical personnel

The physician/population ratio in Uzbekistan, like in other CAR, has fallen slightly since the early 1990s, and in 1997 it was lower than the European average. In recent years, graduates of the country's medical colleges have been trained following the new curriculum, and they now receive multi-stage training from general practitioner to specialized training at master's degree level. Intermediate-level medical personnel also have a clear gradation of specialties, with priority given to training universal specialists in general practice.

Pilot Telemedicine Projects in Uzbekistan: First Steps

Despite the existence of a wide range of telemedicine research projects in various countries, there is good evidence for certain other benefits, in particular for the ability of telemedicine to deliver specialist medical expertise to regions and places which lack doctors. For this reason, telemedicine may be a useful technology in developing countries [6]. Because there is very little practical experience in the use of telemedicine in developing countries, it might seem premature to consider the cost effectiveness of projects as the initial benefit for developing countries will not be a financial one. Really, last face various problems in the provision of medical service and health-care, including funds, expertise, resources. A large number of villages and rural areas have no access to medical advice, even in emergency cases. For the Central Asia (CA )countries telecommunication can provide a solution to some of these problems. The widespread use of telemedicine services could allow universal health access. Telemedicine offers solutions for emergency medical assistance, long-distance consultation, administration and logistics, education and training for health-care professionals and providers. One can see, that in CA region has been an explosively growing interest in telemedicine and telehealth as a means to ease the pressure of health-care on national budgets. It may be that some technologies and experiences of the developed countries could be of help to Central Asia countries in their desire to provide, especially, primary health care. Telehealth should also be of interest to telecom operators since they generate additional traffic to design the first medical networks in CA countries. Really the telecom and health "industries" can achieve synergies.

Central Asia countries are hungry for more information about how telemedicine services could be implemented in order to overcome severe shortages of delivery of primary health-care to remote and rural areas.

The introduction of telemedicine service requires close cooperation between telecommunication operators and health-care authorities. Some practical experiences presented below confirmed, that pilot projects are a good basis for the practical recommendation on how to benefit from the introduction of telemedicine services in our countries.

What is important for us,- to learn how to prepare a model of self-sustaining telemedicine communication systems than would operate without further outside financial support. It become clear, that we have no enough resources for designing separate telemedicine network. The utilization of existing networks for clinical application may be sufficient to sustain a system, because there are the other teleservice applications for different user groups in order to make a self-sustainable business plan by sharing telecommunication facilities between profitable and unprofitable applications in one business package. It is obviously, this task could only be done by the telecommunications partners of telemedicine projects, and it will be a key factor for the future extension of telemedicine service.

Successful introduction of telemedicine requires more that just the delivery of the right equipment to the users. Much more important is to find the right way of how to incorporate telemedicine services in the medical practice and routine clinical consultations. This is also relevant to organizational and administrative matters as well as to efficient training. The level of understanding of telemedicine among the potential end-users is low. There is a need to communicate widely the experiences and lessons learned to the health-care community and to citizens in order to stimulate an awareness of the proven benefits of telemedicine and telecare services. It is important to introduce as soon as possible telemedicine into formal health-care training programs.

The distribution of the Internet in region is changing the way is deployed and the extent to which it becomes widely available. The focus should be on low-cost, low-bandwidth internet applications that facilitate discussion and the transmission of text, data and still images. These applications may complement, but must be distinguished from, applications such as interactive video that require high-bandwidth - a luxury that is still unavailable or unaffordable in all the CA countries. Another significant practical factor in telemedicine implementation is the regular maintenance of the equipment. The availability of cost-effective maintenance of equipment is a factor to be considered in the costing of the service. It is especially important that the equipment does not fail in emergency medicine. So it is necessary to consider these factors in implementing a maintenance regime. Telemedicine can help to develop new ways to deliver medical and health education and to the community and improve the continuing medical education.

Of course there are some barriers before telemedicine implementation arising. The lack of reimbursement has dampened enthusiasm and little telemedicine service has developed, as a first considerable barrier. A second barrier is cultural. There is a generation gap here and in the medical profession at large, with younger participants unable to overcome the resistance of older entrenched interests. Some of doctors fear telemedicine because they see it as threat which may lead to a loss a patient. However, they should see telemedicine as a source of knowledge and information. Overall development is also hindered by a lack of hospital information systems infrastructure. Even if most hospitals will be linked to networks within the next several years, senior physicians show little interest in telemedicine and widespread implementation must await generational change.

Telemedicine in Uzbekistan

Telemedicine in Uzbekistan is at first step of development. This direction of interdisciplinary study was initiated by State Committee of Science & Technology in connection with Health Care System reforming and designing the national model of emergency medicine in country. At March 1999 the "Conception of Telemedicine Development" for the years 2000-2005 was presented and approved by Ministry of Health Care and State Committee of Science & Technology. In this document was formulated main goals and tasks, main trends in implementation, basis requirements for telemedicine systems of emergency medicine. Defining the key points in strategy, attention was paid to highlighting the target groups of IT and telemedicine service end-users.

The starting point for a IT users requirement analysis will come from an understanding of the objectives contained in the development strategy. This will lead to the identification of the key tasks to be analyzed and the related opportunities for improvement through the application of IT. Understanding IT objectives of the organization will allow the process to be focused in two ways:

1. Analysis of tasks that are directly involved in the areas affected;
2. Identification of requirements for IT support that will contribute to the achievement of those objectives.

Keeping in mind above-mentioned theses, here presented the description of working activities, IT applications, IT facilities in central district hospitals in two pilot studied regions under EC grant [7]. The main goals of analysis was to identify the educational levels and skills of personnel during the data collection, data processing .

It were carried out a survey in following rural districts of Fergana region: Fergana-city, Kokand, Margilon, Kuwasay, Olti-arik, Bagdad, Kuwa, Rishtan, Tashluck, Fergana rural district, Yaz'yavan.

In Navoi region the following 3 rural districts and Navoi city were analysed: Kizil-Tepa, Hatirchi, Kamenech .

Key findings from this survey (1999-2000):

1. Status of informatization in Fergana and Navoi regions Health Care system is not adequate.
2. The information flows are very intensive both in vertical and horizontal directions, having mainly logistic features.
3. Information technology applications is weak, because all document producing have been realized by hand.
4. Information technology facilities, - electronic data collection, word processing or electronic mail are not realized yet.
5. All staff of IT groups even in central district hospitals consists only of medical specialists with deficit of skills in IT
6. All physicians, nurses independently of place (city or village) expressed their great wish to learn in field of information technology and Internet.

In order to study the situation in Tashkent was conducted quick survey, which main goal was to identify the level of knowledge and skills on IT between medical staff in research centers and hospitals. The following health care organizations were involved: Republican Center of Emergency Medicine, Republican Information Center of Ministry of Health Care, Ministry of Health Care, Research Institutes of Ministry of HC(including hospitals): (cardiology, pulmonology, urology, surgery, obstetrics&gynaecology, dermatology, oncology, diabetology, pediatrics, gematology). Additionally were included: 1st and 2nd Tashkent State Medical Institutes, Tashkent State Pediatric Institute, Central Military Hospital, Medical Department. of Ministry of Inner Affairs, Medical Department of Ministry of Defence, Republican Ophtalmological Center, Joint-Stock Company "Uzmedtechnika".

To all respondents were put 3 questions:

1. Are you aware of information technologies applications in health care ?
2. Do you consider that IT, particularly, telemedicine can improve quality of health care delivery?
3. Do you need in educational support in field of information technology applications in health care, e.g. in medical informatics?

Most part of respondents (> 90%) was aware of IT possibilities in health care; they think that IT ensure the best level of health care delivery for patients. Absolutely all respondents are considering that it will be very important to get basic knowledge in IT.

The current situation with IT technology implementation can be characterised as unadequate to modern requirements of telemedicine implementation, because of lack of modern equipment, lack of network facilities, lack of medical personnel training in information technologies. In order to overdone educational barrier were designed the "Educational Programs in Information Technology for Health Care Professionals" within SOROS Foundation Grant [8].

Considering the described above situation it was difficult identify the contents of Program and course itself. So were defined the main subjects which should cover specific fields:

1. Introduction to medical informatics, health care delivery systems, information systems planning in health care, medical methodology (including an introduction to medical documentation)
2. Information system management in health care, especially hospital information systems, knowledge-based methods and systems in medicine.
3. Computer-based decision-making, informatics approaches to diagnostics, telemedicine services through Internet.

The situation with computers and e-mail facilities in regions begin to improve due to activities of many International Organizations, such as World Bank, European Commission who have been conducted the collaborative projects in field of Health Care. Thus, due to "Health One" project, carried out by WB in pilot regions were installed the PC with e-mail facilities. The first attempt to design the Information Management system for preventive health care was undertaken within TACIS Program of EC [7]. As a results of last project, in two pilot regions of Uzbekistan (Navoi, Ferghana) centers of health life style promotion were organized in 2001 year. . These centers were supplied by the PC and e-mail facilities. The main goals of this information system are:

• to supply the above mentioned centers by the statistics presenting the demographical, epidemiological, ecological, socio-economical status of population and territories;
• to create data bases of epidemiological, ecological, demographical and socio-economical status of people in small communities ( uzbek spelling,-mahallyas);
• monitoring the basic features of population health status and status of territories, including both the infection and non-infection pathologies.
• Using the Epi-Map 2 software these data can be transformed in visual form in order to simplify the data analysis within monitoring process.

The first telemedicine pilot project preparing in Uzbekistan is "Teleconsultation system for Republican center of emergency medicine". Partners in these project are Telecommunication Development Bureau /ITU, BHN Association (Japan), Agency of Post & Telecommunication (Uzbekistan), Institute of Cybernetics Academy of Sciences (Uzbekistan), Ministry of Health Care (Uzbekistan).The main long-term goal of the project is to connect the Emergency Center with the Research Center of Surgery and with all 12 regional branches of the Center. In the beginning the telemedicine transmissions should be based on store and forward Internet technology between both above-mentioned centers. Later, when the country's telecommunication infrastructure has been upgraded to ISDN, the videoconference facilities are also to be implement.

The first step of Uzbekistan is showing that the following key factors are important:

• Introduction of telemedicine to the required area;
• Human relationship for telemedicine to success;
• Systematic support;
• Cost: Initial cost and Running cost;
• Computer literacy.

Recently, two new telemedicine project are starting.

First of them - point of telemedicine consultation in First Tashkent State Medical Institute. It was set up a simple, versatile, cheap and effective sfore-and-forward telemedicine system, named DMS (Defense Medical System). This system has been in the use around the world since November 1997. The British Computer Socicty awarded the DMS Telemedicine System in Special Award for 1998. This project was sponsored by Swinfen Charitable Trust (UK, President, Lord R.Swinfen). Thanks to this system the patients from Tashkent will take consultations from medical consultation network Health-on-Line, based in Brisbaine, Australia free of charge. Local doctors expressed their intention to be consultants too, but in framework of some commercial services. Therefore, the doctors have awareness regarding to tele-medicine as part of tele-business.

The second new project has been used on the same dms configuration and intends for military and emergency medicine.the sponsor of this project is pims (nato program "partnership for peace - pfp") PFP Information Management System.

Conclusion

Uzbekistan takes the first step to virtual reality. Described above experience of developed countries,and economical demograpical, health status of Uzbekistan gives the opportumemty to conclude that all necessary factors for telemedicine promotion are present.

It is no doubtful that all Central Asia countries need in telemedicine promotion due to their geographical, demographical, and socio-economical conditions. In all the countries the Health Care systems are in process of reforming and one can consider that this moment is appropriate in order to take opportunity to include telemedicine service to health care system reforming program.

Most advanced organizational direction of telemedicine development is in Uzbekistan. There are the Conception of Telemedicine Development, the special working group, consisting of representatives of Ministry of HC, Agency of Telecommunications, Academy of Sciences, heading by National Coordinator on telemedicine. But the possible scenario of telemedicine development depends on unpredictable factors combination and dynamics in future.

References:

1. R.Wooton Telemedicine in developing countries-successful implementation will require a shared approach
   J of Telemedicine and Telecare 2001:7,(Suppl 1):1-6
2. Deborah R.Dakins Market target analysis
   http://www.telehealthmag.com
3. Fran Fields
4. Jeffrey C.Bauer Insights on Telemedicine:How Big is the Market?
   Journal of Healthcare Information Management,vol.16,No.2,2001
5. Highlights on Health in Uzbekistan http://www.who.dk/document/e71959.pdf
6. L. Androuchko Trends in Telemedicine Development
   ITU-D Development Sector Study Group Co-Rapporteur Q 14/ 2 , Geneva,1999
7. EC TACIS Program Grant : EDUZ, 9801,
   "Preventive Health Policies and Programs in the Republic of Uzbekistan", 1999-2001
8. OSI/RSS Grant No: 1083/199
   Educational Programs in Information Technology for Health Care Professionals. Final Report