Review article
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Telemedicine in Armenia Robert S H Istepanian* and Haik Nikogosian{ *Department of Electronic and Computer Engineering, Brunel University, Uxbridge, UK; { Ministry of Health of Armenia, Yerevan, Armenia
Summary Telemedicine in Armenia began with the US Telemedicine Space Bridge programme, which was introduced following the disastrous earthquake in 1988. More recently educational programmes have been established between the School of Medicine at Boston University and the Emergency Hospital in Yerevan. There are also telemedicine activities involving the Internet, for example at the Diagnostica Medical Centre in Yerevan. The future integration of telemedicine and telehealth services within the health services in Armenia will produce significant benefits. Current telemedicine activities in Armenia represent models for collaborative projects in other former Soviet republics with the aim of providing greater access to health-care at higher quality and lower cost.
Introduction
............................................................................... Since the dissolution of the Soviet Union in 1991 there has been considerable economic upheaval in the former republics. Those responsible for health-care planning have considered telemedicine to be an important method of future health-care delivery in these newly independent countries, with important benefits for their new market-oriented economies. In recent years several telemedicine programmes have begun in former Soviet republics, mainly in Russia1,2, Georgia3 and Armenia4. This paper describes some of the current telemedicine and telecare activities in Armenia and the potential of telemedicine applications in an evolving health-care system. Armenia is a landlocked country and is one of the smallest of the independent states of the former Soviet Union (Fig 1). It has an area of approximately 30,000 km2 with a population of approximately 3 million, of whom about 1 million live in the capital city, Yerevan. The remaining population lives mainly in rural communities and cities with poor living standards and limited health-care provision. The Republic of Armenia has experienced the dissolution of the Soviet Union, independence, continuing economic blockade resulting from the war in the Karabagh region
Fig 1 The Republic of Armenia and its neighbouring states.
which followed independence and the difficult economic circumstances that followed.
Telemedicine in Armenia Accepted 20 August 1999 Correspondence: Dr R S H Istepanian, Department of Electronic and Computer Engineering, Brunel University, Uxbridge, Middlesex UB8 3PH, UK (Fax: +44 1895 258 728; Email:
[email protected] )
Journal of Telemedicine and Telecare 2000; 6: 268–272
............................................................................... Telemedicine in Armenia began with the US National Aeronautics and Space Administration (NASA)
R S H Istepanian and H Nikogosian
Telemedicine Space Bridge programme2,4. This was introduced after the disastrous earthquake on 7 December 1988, which resulted in over 25,000 early deaths and 125,000 survivors in need of urgent medical attention. The then Soviet Armenia’s health system was initially overwhelmed. Following this natural disaster, NASA initiated a satellite telemedicine link in early March 1989, the first such telemedical link between NASA and the former Soviet Union. This provided interactive audiovisual and fax links between the USA and two Armenian and Russian medical centres, permitting remote US consultants to assist Armenian and Russian physicians in the management of emergency medical cases. The joint telemedicine programme was operational between 4 May 1989 and 28 July 1989, and resulted in successful interactive emergency consultations in several disciplines, including2 anaesthesia (21 cases), cardiopulmonary medicine (23), intensive care (24), dental forensics (25), dermatology (13), emergency medicine (26), family practice (28), ophthalmology (29) and paediatrics (30). This was the first successful use of satellite-based telemedicine after a major disaster. It demonstrated the ability of remote specialists to provide valuable assistance to physicians by interactive consultation2. However, the disintegration of the Soviet Union and the difficult socio-economic environment in Armenia following its independence in 1991 halted progress in this area. Recently educational programmes have been established between the School of Medicine at Boston University and the Emergency Hospital in Yerevan. The details have been described elsewhere5,6.
Internet telemedicine in Armenia
............................................................................... The most well known telemedicine activities involving the Internet are at the Diagnostica Medical Centre in Yerevan. The Centre has several international collaborative programmes with the University of Maryland and Yale Medical School, which fund its telemedicine activities. The programme with the East– West Space Science Center of the University of Maryland, funded by NASA, involves the study of a low-cost, PC-based Internet telemedicine system for interactive diagnosis, using teleradiology and ultrasound images transmitted between Maryland and Yerevan7 . The telemedicine system provides store-andforward facilities for images and documents such as electronic patient records and teaching materials. The main objectives of the programme are: (1) operation of an Internet-based interactive telemedicine system; Journal of Telemedicine and Telecare
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(2) study of data transmission times using various telecommunication links; (3) provision of realtime voice transmission; (4) study of the quality of images transmitted between Maryland and Yerevan. International transmission was tested in experiments carried out in 1998, using images compressed by either JPEG or wavelet techniques. Different levels of compression were used, depending on the type of image: (1) for radiographic images, JPEG and wavelet compression ratios of 20:1, 40:1 and 60:1; (2) for magnetic resonance imaging (MRI) scans, JPEG and wavelet compression ratios of 20:1, 30:1 and 40:1; (3) for computerized tomography (CT) scans, JPEG compression ratios of 10:1, 15:1 and 20:1, and wavelet compression ratios of 10:1, 20:1 and 30:1; (4) for ultrasound scans, JPEG and wavelet compression ratios of 20:1, 30:1 and 50:1. Table 1 shows the details of the images used in the initial trials. Standard PCs were used, connected to the Internet with modems at data rates of 14.4 kbit/s. The Internet trials showed that files smaller than 1 MByte could be sent successfully, without transmission breaks or noticeable interruptions. Larger files, of 1.25 MByte, were transmitted at approximately the same average speed, but with lower probability of achieving complete transmission (transmission failed in three cases from nine attempts). The transmission of the largest file (3.3 MByte) to Armenia failed in all 10 attempts. Table 2 summarizes the results. There was a significant difference in transmission speed depending on the day of the week and time of day, especially when transferring larger image files. Transmission speed was higher at weekends and on weekday evenings in the USA, which corresponds to night-time in Europe and Armenia. Transmission speed Table 1 The medical images used for the Internet telemedicine tests between Armenia and the USA
Image type
Original file size in TIFF format (kByte)
Scanner settings (dots/inch)
Radiograph, bone Radiograph, lung MRI scan, brain MRI scan, angiography CT scan, brain CT scan, lung Sonogram, abdominal Sonogram, abdominal
1249 3274 212 134 219 100 548 635
4006400 3006300 3006300 3006300 3006300 3006300 3006300 4006400
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Table 2 Results of the Internet telemedicine tests between Armenia and the USA Time (s)
Speed (kbit/s)
File size (kByte)
mean
SD
range
mean
SD
range
4–50 50–100 100–200 200–500 500–1000 1000–1500
35 103 195 198 654 860
33 62 190 190 408 284
1–224 30–289 4–757 26–831 211–1384 621–1361
14 14 13 11 13 16
12 9 8 6 9 5
7 3–40 2–31 3–25 4–31 9–21
was much lower when it was morning in the eastern USA, which corresponds to the end of the business day in Europe, and early evening in Armenia. Such considerations may be important for future teleconsultations. Fig 2 shows examples of Doppler ultrasound images successfully transmitted between Maryland, Yerevan and Gyumri (Gyumri is the second largest city in the country and located north-west of the capital; it was the centre of the 1988 earthquake disaster). Fig 2(a) shows a clinically acceptable image of a stone in the gallbladder and deformation with enlargement of the bile duct. Fig 2(b) shows a patient with hypernephrotic cancer of the left kidney with a metastatic lesion. The diagnosis was confirmed interactively between the USA, Yerevan and Gyumri centres using the telemedicine system described above. Realtime voice consultations between doctors in Maryland and Armenia using either Internet telephony or the conventional telephone network were of high quality: personal identification was achieved regardless of whether the specific person’s presence at the other end was known in advance; voice delay was less than 2 s; and interactivity was maintained without communication interruptions.
Prospects for telemedicine in Armenia ...............................................................................
Telemedicine has socio-economic benefits, especially in countries with limited resources such as Armenia. It is clear from the pilot programmes that telemedicine has advantages and will benefit health-care delivery, especially in remote and rural areas where there are few specialist doctors. These benefits and the corresponding advantages of telemedicine in developing countries were summarized in a recent report8 . With the rapidly declining costs of computing and telecommunications, the level of interest and the corresponding activity in telemedicine can be expected to increase.
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Fig 2 Ultrasound images transmitted over the Internet between Maryland and Yerevan. (a) A clinically acceptable image of a stone in the gallbladder and deformation with enlargement of the bile duct. (b) A hypernephrotic cancer of the left kidney with a metastatic lesion.
In the case of Armenia, the existing medical and academic infrastructure could form the basis of a national telemedicine and telecare system, and might represent a model for the other former Soviet republics to follow. A relatively large proportion of doctors in Armenia speak English. This will support future training and international educational initiatives. There are modern but limited telecommunication links, especially in the capital Yerevan, which are suitable for the initial phases of telemedicine education and training. Since the country is located in an active earthquake region, telemedicine may prove a crucial medical concept in the future.
Requirements for the establishment of effective telemedicine services
............................................................................... The telecommunication infrastructure needs to be modernized and the existing poor-quality analogue, Journal of Telemedicine and Telecare
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Soviet-era equipment replaced. This could allow the use of mobile telemedicine systems in rural and remote areas. Limitations in current Internet provision also present problems for the transfer of large medical image files via the Internet. Telemedicine and telecare projects in the country need to be properly planned and assessed. The framework for economic evaluations of telemedicine could follow similar strategies proposed in the USA and Europe9,10 , taking into account the special conditions in the country. The establishment of telemedicine services must be prioritized, to meet the most urgent needs first, such as mobile and emergency telemedicine centres, and new health education programmes, especially for the elderly and for the wider population living in impoverished urban and rural areas of the country. A strategic organization is needed to ensure the establishment of an integrated telemedicine structure that includes proper funding from both the private sector and the government, with relevant medical training programmes for local doctors to improve their clinical expertise and effectiveness. Successful telemedicine programmes could form the basis for a national telemedicine network to expand health-care delivery beyond existing urban areas. The affordability of telemedicine services must be taken into account. A high percentage of the population are at or below the poverty line, and cannot afford to pay for their health-care or even to travel to specialized centres in Yerevan. Telemedicine and telecare initiatives have the potential to alleviate such difficulties. At present a radical private health-care policy is being planned for the former Soviet republics, using telemedicine services with affordable reimbursement strategies. National telemedicine education and training programmes in tertiary institutions need to be established in Armenia. These can be developed from existing international collaborative links with European and US partners. For example, the American University of Armenia (AUA) has an international medical (public health) faculty, which is equipped with modern computing, telecommunication and faster Internet facilities that are unique in the country and the former Soviet republics. The AUA could forge collaborative links with the State Medical University and other telemedical centres to establish the basis for a national programme. One approach would be to initiate a joint Internet-based telemedicine training and educational programme at postgraduate level with medical partners in the USA and Europe. The funding of telemedicine projects also needs careful consideration. Most of the existing telemedicine programmes in Armenia are funded by Journal of Telemedicine and Telecare
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joint US aid and collaborative academic and research institutions such as the World Health Organization, the World Bank, the Armenian General Benevolent Union, NASA and special USAID programmes and other Armenian charitable organizations. This fragmented approach is characterized by the use of technology for limited educational, research, training and private clinical purposes. A more cohesive policy to fund the country’s telemedicine programme is required. This policy should also take into account the sustainability and cost-effectiveness of telemedicine11.
Conclusions
............................................................................... There have been few previous studies of telemedicine programmes in the former Soviet republics. In these vast regions there are obvious benefits in using telemedicine and telecare to improve the delivery of health-care. The advantages include reducing costs, bringing specialist expertise to patients, especially in rural and remote areas, optimizing diagnosis and treatment, and improving the quality of professional medical education. These issues are critical for developing an improved health-care system given the economic circumstances of the area. The use of telemedicine to improve and restructure health-care delivery in Armenia could form the basis of similar programmes in other former Soviet republics. Further international collaboration is under way to provide wider use of telemedicine, especially in countries with large impoverished populations, scarce health-care resources and limited income.
Acknowledgements: We thank Dr Haroutiun Mouradian from the Diagnostica Medical Centre, Yerevan, for providing the medical ultrasound images. We also thank Professor Ara Minasian and Dr Anna Boshyan of the Emergency Scientic Medical Centre, Yerevan, for their helpful comments on the Yerevan– Boston University telemedicine programme. Dr Istepanian is grateful to the American University of Armenia and to Professor Armen Der-Kiureghian, University of California, Berkeley, for support during his academic visit to Armenia and AUA.
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and Diagnostic Medicine. Final Report, NASA grant NAG 5-3532. College Park: University of Maryland East–West Space Science Centre, 1997: 1–20 Wright D. Telemedicine and developing countries. Journal of Telemedicine and Telecare 1998;4 (suppl. 2):1–88 Sisk J, Sanders JH. A proposed framework for economic evaluation of telemedicine. Telemedicine Journal 1998;4:31–7 Istepanian RH. Telemedicine in the United Kingdom. Current status and future prospects. IEEE Transactions on Information Technology in Biomedicine 1999;3:158–9 Wright D. Can developing countries afford telemedicine? In: Wootton R, ed. European Telemedicine 1998/1999. London: Kensington Publications, 1999: 35–7
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