Some healthy change
Editor's note: Tatiana Barakshina is a co-founder and a managing partner of research firm Bazis, with offices in Ekaterinburg, Russia, and Naperville, Ill. The author wishes to thank the Bazis health team for contributing to this piece: Dinara Akhmatdinova, Anna Shevalova, Katharina Gancarczyk, Anastasia Leonteva, Marina Petrunya and Evgeniya Zaburunova.
Medicine is one of those continuously evolving fields. As researchers, one of the joys of doing what we do is to observe the industry developments and trends, to be in the midst of advancement, evaluating and studying how we provide care for people in need.
We see it from several vantage points: from our office in the Chicago area but also from our headquarters in Ekaterinburg, Russia, where we do most of our fieldwork in this space.
I’ve noticed a handful of hot trends in medicine being actively discussed in the United States. Given where we conduct our research, I wanted to answer the question: What is the view and status of these trends in Russia and Ukraine or Kazakhstan – countries which are geographically, culturally and linguistically connected?
In this article, we’ll explore some of those trends across Russia and the region: telemedicine, electronic health records (EHR), natural language processing (NLP), online customer reviews and the quantified self (wearables).
Dial-a-doctor: the role of telemedicine in Russia
While telemedicine has gained popularity within the U.S. health care system only recently, the idea of doctors using this type of communication to consult with patients has essentially been around since the invention of the telephone in the 1870s.
In 1925, Hugo Gernsback, a radio and publishing leader, predicted physicians would use the radio and TV to communicate with physicians (this may have been in part wishful thinking on his end given the industry he was in). In any event, as early as 1960, physicians were connecting with patients via closed-circuit televisions for consultations (a psychiatric institute was connecting with a hospital in this case).
Fast-forward to 2016, when the federal government of the U.S. invested money to use technology to better connect rural veterans to doctors for consultations. Moreover, medical groups use telemedicine as an extension of customer service – it is used typically in a consultation and as a form of convenience for patient and doctor. Telemedicine is a widely accepted way of making introductions and connecting patient and medical providers.
Telemedicine can be applied broadly in the following areas: primary health care; specialized medical care; urgent medical care; and palliative medical care.
Russia has created a new telemedicine law to address the growing use of telemedicine to set standards of how it is to be used. It points to the demand for this in some parts of the country (typically in urban centers among a younger generation who is already using technology widely).
The new law permits online consultations including one or several physicians, online patient management and the creation of informational systems containing data about patients. It does not allow for a diagnosis to be made online. Also, importantly, the first visit must be personal for diagnostics.
There are a couple of reasons Russia is both using and addressing telemedicine. The distances between hospitals and the people who need them can be far in some parts of Russia (it is, after all, the largest country in the world by landmass). Online consultations can be many times cheaper than for people to travel to a health care center.
So how are Russians using telemedicine? One way is through a platform called Qapsula. It offers free consultations to patients and includes 3,000 specialists from all regions in Russia. The range of physicians includes everything from endocrinologists to dentists.
A few platforms provide free chat with physicians but the chat is made public. These include Medotvet and Health Mail.ru. Other platforms offer paid consultations. These include Online Doctor and Doc+. The cost comes out to around 800 rubles ($12).
Russian search engine Yandex also offers a special platform known as Yandex.Health. Through this, patients can chat or have audio or video conferences with physicians. Express consultations cost 99 rubles ($1.50) or regular consultations cost 499 rubles (about $7.50). A variety of specialists, along with general practitioners, are available for consultations. The specialists are based in Moscow and have gone through special training courses to consult online.
One final place Russians turn to is a platform called European Medical Centre (EMC). This is different from the other platforms for a couple of reasons. First, the cost is extremely high compared to the others (over 12,000 rubles or $160). But, EMC positions itself as a leading center and a patient can get an opinion from specialists in Russia, Israel, the U.S. and across Europe.
The users of telemedicine in Russia tend to be women as some of the most popular areas are gynecology and pediatrics. It is typically a woman who asks questions about children’s health in Russia.
While the pros of telemedicine include the savings of time and money, efficiency in reply time and availability of specialists, others are not using telemedicine in Russia because of some concerns around it. As with any technology including personal information, there are issues about data security. People are concerned that their health data could be disclosed. There is also the obvious boundary of telemedicine not being something where a doctor is physically observing a patient. Moreover, the video or photo quality may be less than ideal, which makes it even harder for the doctor to provide advice. And, as previously mentioned, low availability of Internet in rural areas inhibits the use of telemedicine.
Natural language processing in Russia and the region – hindered by EHR
Natural language processing (NLP) could be critical in helping make health care decisions but there are a number of obstacles before it can really have a major impact in medicine.
As a refresher, NLP is an overarching term to convey when we use computer algorithms to identify key elements in everyday language and extract meaning from unstructured spoken or written input. It is a computer science discipline that requires skills in artificial intelligence, computational linguistics and other machine learning.
It can help with enhance accuracy of electronic health records, provide meaningful medical information through free-text queries and could make documentation easier. But probably the biggest news in how NLP is being used in health care is via IBM’s Watson (i.e., used to flag patients with a risk of heart disease). That kind of predictive care could be critical in preventing serious conditions for patients.
Before considering things like natural language processing or AI in medicine, we really need to look at electronic health records. Natural language processing needs sound electronic data to make its mark.
Electronic health records have become the norm in the U.S. and in other western countries. However, the situation is different in Russia. While the history of EHR traces its roots to 2007 when Russia introduced the first electronic program to create digital patient records, more than a decade later the Russian health care system has yet to make a full transition to nationwide EHR. But it appears to be getting close. According to the Russian Ministry of Health, 95 percent of medical organizations are en route to switching to EHRs. In practice, however, it is still very difficult to achieve this goal.
The Ministry of Health is taking steps to standardize medical health records. In January 2019, it announced a special program to create a united medical IT system. However, it’s still unclear when EHR will be fully uniform in Russia.
A lack of uniformity is a challenge in Russia as a number of hospitals in major cities like Moscow have an EHR system but one that is different from other hospitals. It makes transferring data from hospital to hospital cumbersome and time-consuming.
The biggest challenge is converting existing patient health records into a unified system. Statistically, people only see a doctor every three or four years in Russia. Beyond the logistical issues, there is also an uphill battle in convincing people that EHR is safer than the current system.
The records of newborns and infants are easier to digitize. One example: the children’s polyclinics in St. Petersburg are planning to record all young patients’ records electronically this year.
Overall, Russia understands the need to formalize EHR and has put in place plans to do so but the transition may still take some time and it is unclear when the country will truly have a uniform system in place.
Looking at neighboring Kazakhstan, the government there has put a major emphasis on the state program “Informational Kazakhstan 2020,” which also includes major development of the medical sphere until 2020. The government plans to launch a uniform EHR system in the whole country, which will require all medical professionals to keep track of their health records electronically. Each patient will also have their own health care number, which will allow any medical institute across the country to access the patient’s health record. By the end of 2019, Kazakhstan’s goal is to have all hospitals and medical institutions incorporate this new system.
Another neighboring country, Ukraine, is taking a page out of Kazakhstan’s playbook and introducing a program that should enable all hospitals in the country to have access to a national database where EHRs will be kept. Ukraine is starting pilot projects in 2019 and wants to digitize all health records by the end of 2020. After that, only EHR will be used, according to the plan.
While both programs in Kazakhstan and Ukraine sound very progressive, they are still in an infancy stage and it is not known whether they will really be launched completely in the next 12 to 24 months as is planned.
So, before looking at implementing natural language processing and AI in medicine, these countries need to first streamline EHR systems and make it the norm.
’How well did I do?’ The state of physician reviews
Patient reviews of physicians have become increasingly popular in Russia. Anywhere from 15 to as many as 30 percent of patients in Russia use reviews when choosing physicians. Using reviews in Kazakhstan and Ukraine is less popular, at least for now.
In Russia, there is a positive correlation between the cost of the service and the time spent on analyzing reviews. People who are spending money on physicians choose differently to compare to those being treated at free public clinics. Patients without experience are more likely to be guided by the recommendations of others.
According to Yandex WordStat, there are 113,375 queries per month in Russia containing the words “reviews about physicians.”
The number of patients using online reviews is on the rise. From 2016 to 2018, there was a 15 percent increase in the use of online reviews in Russia. Some of the popular websites include ProDoctorov.ru, Napopravku.ru, Yandex Health (in Russia), Med Element (in Kazakhstan) and Otzyvua.net in Ukraine. Russia’s largest federal site with reviews, ProDoctorov, has collected more than 1 million patient reviews.
One of the unfortunate consequences of the review system is that some doctors, fearing bad reviews, make decisions based on what the patient wants instead of solely on a medical basis. This is particularly a concern with paid health care offerings.
Moreover, there are cases of deliberate negative reviews being posted due to competition among physicians. In some cases, doctors in Russia have even had to press charges because of deliberate negative reviews.
If the reviews are poor but unbiased, the administration of the clinic typically engages the patient who wrote the poor review. Depending on how many bad reviews there are and the claims, Yandex.Health will remove physicians with bad reviews from its database.
Many patients use online reviews before they choose a physician or to evaluate their current physician after having selected one. This data highlights how important reviews are for both the physician and patient in Russia.
Are digital devices and apps a means to better health?
Smart devices and social media have transformed the way people care for themselves. One trend taking flight across Russia (as it has in other parts of the world) is digital services and apps that both monitor existing medical conditions and maintain a healthy lifestyle.
Let’s look at some areas in which digital devices are particularly transforming the way Russians care for themselves.
Devices and apps for diabetics. Noninvasive diagnostics for diabetes involve devices and gadgets that perform measurements without cutting skin or entering the body’s space. There are some devices like these available in Russia but they tend to be expensive. Others have been developed but are not authorized yet. The device isn’t the only cost patients accrue with devices like these; they also need to pay for the accessories used with them.
There are two glucose meter models that come in the form of bracelets that are popular among diabetes patients – the Glucowatch and Omelon, a blood pressure and glucose monitor.
The Omelon B-2 is perhaps the best-known noninvasive device used for both adults and children. In addition to measuring glucose levels, the device also measures blood pressure. Its working principle is like a blood pressure monitor but the device also includes a sensor for thermal spectrometry and detecting glucose levels. Results are simply displayed on the device’s screen. However, it’s not portable.
Another device, known as the Dexcom G5 mobile, measures glucose levels in the interstitial fluid automatically every five minutes. A small, reusable transmitter connects to the sensor wire and sends real-time readings wirelessly to a receiver. It displays both current glucose levels and historical trends for the patient.
Some apps that patients are using in Russia include Diabetes: M, the Glikemichesky Index (Glycemic Index) – which has 467 average daily downloads in Russia – and the Glucose Buddy.
Devices and apps for pregnant women. There are a number of devices and apps that pregnant women across Russia, Kazakhstan and Ukraine use as support during pregnancy. Here are a few devices that stand out:
Kicktrack: This smaller device measures the time between labor contractions and the duration of the contractions themselves, which gives women an approximate idea of when the labor will be over. The device can also count a baby’s kicks and movements.
Bellybuds: This device makes it possible for an unborn baby to listen to its parents’ favorite music. It aims to form a bond via speakers that safely play soothing sounds directly to the womb.
BIO bands: BIO bands help mothers with morning sickness. The adjustable wristband applies continuous acupressure to specific points at the wrist to get rid of discomfort.
Bellabeat Leaf: Worn as a kind of piece of jewelry, this device monitors sleep, tracks daily activities, measures stress levels and counts number of steps taken. The device is useful for mothers-to-be who lead an active life before pregnancy.
And here are a few apps that have become increasingly popular:
Pregnancy+: This app follows a pregnancy week by week. The app is also used by soon-to-be fathers, grandparents and other family members. The tracker includes a personal diary, doctor visit log, kick counter, pregnancy weight log and baby shopping list as well as thousands of baby names.
Mom.Life: The app is designed for tracking pregnancy as well as a baby’s development. Mom.life also allows other moms to chat via the app, offering support and answering any questions they have.
SMSmame (SMStoMom): This app provides free tips and guidance from leading gynecologists, neonatal specialists, pediatricians and psychologists. The tips and guidance are consistent with pregnancy term or the baby’s age.
9 mesyatsev (9 months): Especially popular in Kazakhstan, women using this app keep track of what is going on during pregnancy through a digital diary that records and remembers the story of starting a new life.
Fitness apps. As is true worldwide, there are plenty of fitness apps used across Russia, Kazakhstan and Ukraine. Here are some of the most popular ones and in which country they are gaining popularity.
Sworkit: This app is quite popular in both Russia and Ukraine. Users tell Sworkit the type of workout they want (strength, cardio, yoga or stretching) and the amount of time (anywhere from five minutes to an hour) and the app delivers moves to follow during a “sweat session.”
Freeletics: This app offers a lot of features, clear and comprehensible exercise demonstration and elaborate workouts and regimens both for beginners and experienced athletes. Freeletics is popular in Russia, Kazakhstan and Ukraine.
RunKeeper: This app is very popular in Kazakhstan. Initially designed for runners, it soon outgrew its intended purpose to become a social networking platform for healthy lifestyle enthusiasts. RunKeeper has a set of features typical for such fitness trackers. A GPS sensor allows tracking runs and walks and calculates speed and distance covered.
Embrace and digitize
Russia, Kazakhstan and Ukraine are running alongside many other countries to embrace and digitize health care. In many ways, Russia is actively participating in some of the hot trends (particularly telemedicine, reviewing physicians and using digital services to monitor and improve their personal health). Kazakhstan and Ukraine use these services to some extent and to varying degrees. Russia spends more per capita on health care than Kazakhstan and Kazakhstan spends more than Ukraine.
One fundamental area that all three countries are striving to improve at a national level is the use and standardization of electronic health records. Advancements in this area will open the use of natural language processing to potentially make these respective health care systems more efficient, predictive and ready to adapt to every patient at a moment’s notice.