Correspondent: Leonid Malkov, Editor, Computer Technology in Medicine (Russian language magazine);Vice President, ParaGraph International. U.S. phone: 408/364-770; malkov@paragraph.com. With Lia Belenkova.

There are some interesting similarities between Russian and U.S. telemedicine. Both have grown up with and been shaped by the space program, and both are to a great extent driven by serious problems with access to medical expertise in rural areas.

The technology developed for transmitting medical information from space stations and spaceships to earth was used extensively after the Armenian earthquake of 1988, and after the Ufa gas pipeline explosion in 1989, in which many people were injured. Currently the Russian Center for Space Biomedicine (which is in fact a telemedicine center), Moscow State University, and the Institute of Medical Biological Investigation are collaborating with NASA through an agreement by the Gore-Chernomyrdin Commission. Among other things, this collaboration includes creation of several Silicon Graphics workstations for medically related video sessions between hospital in Russia and the U.S.

The Russian Republic and all of the former Soviet states have very underdeveloped telecommunications infrastructures, and do not have the capital resources to improve this situation. Fortunately, in 1992 an American financier, George Soros, donated $100 million to support science in the countries of the former Soviet Union. One of the outcomes of this has been development of a University-based Internet project, tasked with creating a new generation of Internet users. The first University Center opened in June, 1996 in Yaroslavl; the second will open soon in Novosibirsk. In all, 32 regional universities will be linked. Also, the South Moscow Supportive Network (SMSN) is being upgraded to fiber and will support 100Mbps transmission. The SMSN is essentially a Wide Area Network and provides Internet access and computer networking for leading medical, scientific, and educational institutions in Moscow and St. Petersburg. The SMSN is currently an interesting hybrid network consisting of four data channels. Two of these operate via satellite, which allows very high throughput but suffers problems with dependability and delay in signal passage. The other channels are land based. Access to the SMSN trunk is via regular phone lines or via ISDN lines for higher-end users. Another network under development is the RUNET (Russian University Network), financed by the Ministry of Science, that will presumably link with and extend the SMSN.

The Russian telemedical community feels strongly that development of the telecommunications infrastructure is crucial for advancement of telemedicine. Not only does it support "low-end" telemedicine applications like Web-based medical education, still image archiving and distribution for modalities such as telepathology, and passage of email and medical records. It also raises professional and public awareness of the potential contribution of telecommunications to patient care, and opens the gates to perceiving the potential of "high-end" applications such as interactive teleconsultations. Many Russian telemedicine applications are now POTS (Plain Old Telephone System)-based, but even that is hampered by the fact that the quality of many of these lines is poor, and cannot reliably support high speed, unbroken modem data links.

Satellite-mediated applications have been piloted in Russia, most prominently several international case conferences via the International Telebridge. These have typically run at 128 Kbps, and have linked the Department of Medical Science at Moscow State University to Baylor College of Medicine (Houston, TX) in the U.S. and to University Hospital of Troms¯, Norway. Other links have been to telemedicine centers in Moscow, Novosibirsk, and Ekaterinburg. While screen resolution for these conferences was high, the low bandwidth made for poor motion handling, and satellite transmission delays of up to three seconds have made true interactivity a challenge. The screen resolution of transmitted radiographs and pathology slides appears to be adequate, at least for teaching purposes.

Elsewhere throughout the countries of the former Soviet Union, telecommunications and telemedicine infrastructure is being supported by the American International Health Alliance (AIHA - http://solar.rtd.utk.edu/friends/health/aiha/aihadir/AIHADIR.HTM), which has the mission of improving ties between medical systems in the U.S. and in the newly independent states. For example, in the past year there have been eight teleconferences between Boston U. School of Medicine and hospitals in Yerevan, Armenia using Winrad technology and VTEL equipment.

A regular link has been established between Arkangelsk Medical Academy in northwestern Russia and Troms¯ Regional Hospital in northern Norway, using regular phone lines and modems as well as periodic higher-bandwidth digital links. This has been used both for patient care and for teaching. Telemedicine in this extremely northern part of Russia is seen as a high priority because of the high costs of transporting patients for specialty care, especially in the winter.

On a more local level, the Moscow office of Paragraph International is developing a new kind of cardiac monitor which enables ECG transmission over regular phone lines (http://russia.paragraph.com/mobile/mobile.htm) directly from patient homes, using palm-top computers.

An indicator of the perceived importance of telemedicine in Russia is the development of a new curriculum and specialization in telemedicine at the Arkangelsk Medical Academy.

Conclusion

Russian telemedicine is at an important crossroads. The need is clear, and professional enthusiasm is high. There are two major factors determining growth over the next few years: first, whether the federal government decides truly to commit to health care as a national priority; and second, whether the telecommunications infrastructure is developed enough that it can adequately support reliable, timely transfer of large amounts of medical data.