In the frame of the Ukraine Swiss Mother and Child Health Programme – a project funded by SDC – a model for the integration of Information & Communication Technologies (ICTs)  in clinical practice has been tested. The model was piloted with the third level Perinatal centres or maternities and the central district hospitals in the two regions of Ivano-Frankievsk and Volyn in Western Ukraine.
Ukraine has huge geographical dimensions with an area of fourteen times the size of Switzerland. The public transport system relies on a weak and slow transport infrastructure which makes travelling rather difficult and costly. Despite the considerable changes since the independence from the Soviet Union in 1989 the country is strongly centralised and oriented towards the capital Kiev.

The health system is strongly centralised as well with most national referral centres located in Kiev. The organisation of the health system remains hierarchical and expert knowledge is pooled mainly in the capital. The national head Neonatologist in Kiev determines the policy and is the clinical reference for the entire Neonatal community. Clinical practice guidelines once elaborated on this highest level trickle down through the entire health system until they reach the lowest level of the primary health care if ever. This hampers the efficient dissemination of new knowledge.

Continuous medical education (CME) is centralised and clinicians have to attend a two month training course every five years in Kiev, which is the only officially mandated education training for health professionals. In the time in between they are disconnected from the developments in clinical practice. The circumstances highlighted above lead to the situation where health professionals working at the periphery relay on outdated material which does not comply to EBM standards in their clinical practice.
The main objectives pursued with the integration of telemedicine in the clinical practice are as following:

• Enable health professionals to overcome professional isolation while sharing experiences and expertise with colleagues through all levels of the health system vertically and horizontally.
• Stimulate the self directed learning process of the health professionals and contribute to the increase of professional skills apart from the regular official continuous medical training.
• Provide a platform for a network of health professionals consulting each other in clinical cases and contribute to improved health service delivery.

The technical implementation is based on an open source software platform called iPath. iPath is a web application consisting of a data base, a structured user interface and communication features. The basic technical infrastructure required consists of a personal computer, internet access and a digital camera. The major aspects to be monitored are the integration of the Telemedicine application in the daily clinical routine process, to assure physical and timely access to the Telemedicine Work Place and to ensure the moderation of the network. The moderation of the discussions and the monitoring of the activities are important aspects directly influencing the quality of interactions and benefits of the network.

Currently the network includes more than 300 national and international registered participants from referral centres and regional and district health centres. So far more than 300 clinical cases have been presented for discussion with an average of 5 to 10 cases per month. The main requests of the participants are related to consultations (second opinion) and to a lesser extent the sharing of information. Consultations aim mainly for the confirmation or specification of the diagnosis or treatment procedure and to a lesser extent to medication strategies.
Further aspects of interest to be evaluated are the impact of the application of Telemedicine on patient referral, the amount and relevance of knowledge gained through the network and the response time and acceptable delays for second opinion cases.

Experiences with the development of the network have shown that English is so far not widely spoken in the Ukraine context. This hampered the communication with international experts and kept the number of participants and activities at a low level.
Once the telemedicine platform was upgraded to allow the use of Ukrainian and Russian language, the participation rate increased sharply. However, at the same moment international exchange decreased while national exchange increased steadily. The inclusion of district hospitals and the creation of regional networks responded to the need for second opinion of the districts. There is a large community of passive participants (no active contribution to the network) which takes its benefits from the presented cases for their individual continuous medical education. The platform therefore serves as a pool of cases for problem based learning.
One can conclude that Telemedicine supports the Ukrainian health system particularly in the field of continuous medical education, in availing information or expertise to the place where it is requested; and in availing information or expertise to everybody at the same time.

Marc Blunier, MSc.

http://ipath.ukma.kiev.ua/

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the photos below show screenshots from iPath, a map of Ukraine displaying the project area and some impressions from the Telemedicine component.