Programs & Projects
Strategic Plan of Long-Term Development of eHealth Applications and Services in Armenia (eHealth Master Plan)
Promotion of Home Telehealth Services, and Development of Mobile eHealth Applications in Armenia.
Development of Cloud-Based Telemedicine and eHealth Platform
Support for Development of Integrated Health Information System in Armenia (Armenian eHealth Program)
Armenian Association of Telemedicine (AATM) Successfully Completed Pilot Telemedicine Project in Nagorno-Karabakh
November 30 – December 3, 2010: Armenian Association of Telemedicine (AATM) conducted a pilot telemedicine project with healthcare facilities in Nagorno-Karabakh (an Armenian-populated territory at the eastern border of Armenia), which provided multi-specialty teleconsultations to a number of local patients with various conditions presenting a diagnostic and clinical challenge, and thus significantly optimized their management.
Armenian Association of Telemedicine (AATM) conducted its second telemedicine project which established and operated a fully functional telemedicine connection between a primary health care facility in Stepanakert, the main city of Nagorno-Karabakh, and the central office of AATM in Yerevan, Armenia. This project, endorsed by the authorities of Nagorno-Karabakh and conducted in association with the Union of Information Technology Enterprises of Armenia (UITE) and telemedicine R&D company Symotec LLC, was the second initiative of this kind, after establishment and successful exploitation of the demonstrational telemedicine system within the framework of USAID-funded project titled “Capacity Building of the Armenian Association of Telemedicine to Result in Improved Primary Health Care Services in Armenia”, in April-June, 2010.
The telemedicine system consisted of two PC-based telemedicine stations. The referral station was set up at Armine Pagoumian Polyclinic Center – a modern multi-profile primary health care facility centrally located in Stepanaker, the main city of Nagorno-Karabakh. The consult station was based at the AATM’s central office in downtown Yerevan. Both stations were equipped with desktop and laptop computers and simple video-conferencing devices – standard web-cameras, LCD monitors, microphones and speakers. The high-speed internet connectivity was established between the two stations providing a bandwidth of up to 2 Mbps. On the consult side the connection was managed by Armenian Datacom Company (ADC); while at the referral site the local ISP, Karabakh Telecom, provided the connectivity as an in-kind contribution to the project. The referral site was also equipped with a set of medical devices (telemedicine peripherals), which included: a 5-parameter vital sign monitor (BP, HR, SaO2, 3-lead ECG, and body temperature); a digital stethoscope with Bluetooth connectivity (3M™ Littmann®) and tele-auscultation software (Zargis Cardioscan™); ultrasound scanners with ultrasound digitizing device and sharing software (by Symotec); an ophthalmoscope (by Welch Allyn) with camera unit (AMD Telemedicine); a digital examination camera (AMD Telemedicine); and a standard 10-MP, 10-optical zoom digital still camera. For telemedicine encounter management the system utilized a dedicated server and database capabilities provided by the organizers.
The system operated throughout one working week, from November, 29 to December 3, 2010. During this five-day program direct tele-consultations were delivered in variety of specialties, and a total of 19 patients presenting to the referral site were examined and consulted by leading specialists in Armenia. On the first teleconsultations day, November 30, three patients suffering from chronic heart conditions were presented by their local managing cardiologist, Dr. Inessa Adamyan from Stepanakert, examined on-line, including real-time echocardiography, and discussed with chief specialist of the National Institute of Cardiology in Yerevan (the leading specialized cardiology clinical, teaching and research center in Armenia), Associate Professor of Cardiology, Dr. Aram Chilingaryan. The patients’ management was thoroughly discussed by the presenting cardiologist and the consultant, and necessary refinements were made in their treatment to achieve better control. On the second day, December 1, four patients with different eye conditions were presented by ophthalmologist Dr. Marina Tevosyan from Stepanakert, and consulted by Dr. Armine Hovhannisyan – one of the leading specialists at Malayan’s Eye Center in Yerevan (the largest specialized ophthalmologic clinical, educational and research institution in the country). Besides patients’ presentation and clinical discussion, the tele-ophthalmology sessions also included tele-ophthalmoscopy and ultrasound examination of the eyeball performed in real-time, with the remote consultant watching live, commenting and tutoring on the instrumental studies. These resulted in optimizing treatment approaches in all cases, obviating the need for referral to a specialized facility.
On the third day, December 2, local radiologist Dr. Elina Sahakyan presented five patients with various radiologic findings requiring further differentiation and work-up (including thyroid disease, post-mastectomy, and liver masses), for real-time tele-ultrasound exam. The consultant radiologist, Dr. Ara Sinanyan – the chief radiologist at the Center of Family and Reproductive Health of the University Clinics in Yerevan, who also runs private radiology practice, was able to effectively “examine” the patients distantly, with the aid of the signal digitizer and sharing software, giving directions and instructions to the presenting physician. All cases presented considerable diagnostic difficulties, and expert opinion of the highly experienced consultant helped the local radiologist come to a definitive decision regarding the ultrasound pattern in each case. Dr. Georgi Chaltikyan, Associate Professor of Surgery and President of AATM, who was present during the telehealth sessions, provided also recommendations regarding further management of the patients, including the need for additional examinations, or referral to a tertiary care center where appropriate. “This unique combined clinical-radiologic format of tele-consultations, which was utilized during this project for the first time in the country, proved highly efficacious means of optimizing patients’ management; that format holds promise in providing a model for subsequent development of real-time specialist telemedicine in Armenia, and will undoubtedly lead to wide use of such tele-consiliums throughout the healthcare system in the near future”, commented Dr. Chaltikyan.
The last day of that exciting and highly productive “telehealth marathon” had also the most caseload. Four local dermatologists (Drs. Gayane Sargsyan, Haykuhi Parsadanyan, Gayane Petrosyan, and Angelika Balieva) presented seven patients during 3-hour long tele-dermatology session with Dr. Davit Asmaryan, the founder and director of dermatology and cosmetology clinic “ARIG-Med” in Yerevan running one of the busiest private dermatology practices in the country. While the patients were being presented by their managing physicians, interviewed by remote expert, and examined in real time using AMD’s high definition examination camera, the AATM assistant at the referral site obtained high-resolution close-up still images of the lesions using the digital camera, and uploaded them into the secure patients’ database on AATM’s dedicated server, making them immediately available for the consultant to review and conclude on diagnosis and treatment. The session yielded an alternative diagnosis in three of the seven patients, while in others led to important modifications of treatment and follow-up recommendations.
The initiative was warmly welcomed and embraced by both physicians and patients at the referral institution, who were extremely pleased and excited by the opportunity to have expert consultations with leading healthcare specialists in Armenia while at the same time remaining at their locale. The healthcare system in Nagorno-Karabakh (population of about 140,000) is tightly connected to that of Armenia, and frequent lack of experienced and highly skilled specialists in the region, as well as absence of specialized health institutions (such like specialized institutions for cardiology, ophthalmology or dermatology), which are understandably concentrated in and around Yerevan, has led to many patients being referred to metropolitan facilities. Meanwhile the only available today connection options between somewhat isolated mountainous territory and Yerevan are either a 4-to-6-hour-long tiring drive on a motor road, more than three quarters of which wind around the mountain slopes, or irregular commercial helicopter charters. “Many times patients would make all the way to Yerevan to see an expert not available locally, only to be examined and told that their management was adequate. Newborn babies with congenital heart disease are almost immediately referred to Yerevan if stable enough to withstand the transfer – once again, frequently simply to be examined and put on waiting list for surgical correction (if the condition permits). Consider how many times a day the need emerges to safely and effectively triage patients presenting with acute coronary syndromes, and to select those who might benefit from immediate transfer to a cathlab. [There is currently no open heart surgery, neither interventional cardiology available locally.] Just imagine how much time, effort, and money, and most importantly – even lives, could be saved only in the domain of cardiology, if we had that timely expertise brought to us via the use of telemedicine, including real-time ECG and echocardiography!” – says deputy chief healthcare administrator of Nagorno-Karabakh, Dr. Alen Poghossyan.
Despite the fact that Armine Pakoumian Polyclinic was equipped with a set of video-conferencing equipment (by Polycom) and a few telemedicine peripherals (mostly by AMD Telemedicine) back in 2006, with joint efforts by “Arabkir” Medical Center (one of the few tertiary care institutions in Armenia running own telemedicine program) and Hayastan All-Armenian Fund, apart from several distance learning seminars organized under the auspices of the Yerevan State Medical University, little if any clinical telehealth has been done so far, and the expensive equipment that had been obtained and donated, installed and made functional, simply remained idle for most of the past few years, points out the director of the polyclinic, Dr. Armen Khachatryan.
Speaks Dr. Inessa Adamyan, young cardiologist who has been trained in Yerevan, and currently works in the polyclinic where the referral site was organized: “The availability of on-demand teleconsultations for our patients would be a truly invaluable addition to our clinical practice. These patients, many of them with multiple chronic conditions, such as hypertension, coronary disease, congestive heart failure, diabetes, and COPD, are frequently a management challenge. They are often referred to highly specialized centers if their condition deteriorates, as expertise of that level is typically unavailable locally. If we knew that our efforts were always backed by an opinion of a senior consultant, that would very much relieve our feeling of professional isolation, allowing us to cope much more confidently with difficult clinical scenarios”. “Telehealth provides us with brilliant opportunities for professional growth and continuous education”, – adds Dr. Marina Tevosyan, an ophthalmologist from Stepanakert, who frequently visits Malayan’s Eye Center in Yerevan for various CME courses, as well as for her research project. “A single teleconsultation with a senior specialist can enrich your clinical skills and widen your professional scope more than few months of practice in isolation”.
“It is amazing that we can see a very experienced doctor, a professor from Yerevan, all while visiting our local doctor here, in Stepanakert”, says N.S., the daughter of an elderly man with chronic heart failure, diabetes and lung disease. “How many times we were advised to travel to Yerevan, and to hospitalize him in a specialized unit to achieve some compensation, before we could continue caring for him at home! I understand when our doctor urged us to do that, because their [remote specialists’] experience is greater, and she felt it would be safer to do so. But imagine our situation, when we need to arrange a taxi that costs 30,000 drams [ca USD 100], leave my children with other family members, and face that long and uncomfortable trip, and then stay for indeterminate time in Yerevan. Quite a few times I had nothing to do but to sleep on a bench in the corridor on the hospital ward where he was treated, because I simply couldn’t afford a hotel room, and we have no relatives or friends living in Yerevan. If that televised consultations obviate the need for even single such trip, I will passionately embrace it”.
Considering the above described, it is not surprising, that authorities in the region are determined to give the people of Nagorno-Karabakh a regular and fully-functional telehealth program. The initiative materialized earlier this fall, in October, when the UITE organized satellite forum on modern applications of ICT in Stepanakert, which featured also a roundtable dedicated to telehealth, moderated by AATM General Secretary, Dr. Davit Gasparyan. During that session an agreement was reached that AATM would implement a pilot telemedicine project to demonstrate the capabilities of telehealth in improving local healthcare services, and to serve as a model for future large-scale program. Mr. Karen Yesayan, chief regional administrator for economy and finances, who is the principal local coordinator and enthusiastic promoter of the program, explains: “Today modern Information and Communication Technologies are crucial not only for sustained economic growth and effective business management; their wider penetration into the society will facilitate multiple aspects of everyday life of our citizens. Telehealth is one such application that will significantly improve the quality of healthcare, and help our doctors more effectively treat their patients, all the while saving significantly on unnecessary transfers to outside healthcare institutions.”
This pilot project is considered the first step in a long-term initiative of telehealth network establishment in Nagorno-Karabakh, which is planned to commence next year. AATM is currently preparing a working plan of deploying regular telemedicine connection between Stepanakert and Yerevan, which should be gradually expanded to incorporate other medical institutions throughout the territory. It is planned that the proposed network would include both stationary sites (one major in the main city, and a number of secondary originating sites at smaller clinics), and a mobile unit equipped with a minimum of telemedicine peripherals and satellite or wireless connectivity, which would be used to rapidly address the need for specialty expertise of the most isolated and underserved communities. Dr. Sergey Movsisyan, chief healthcare administrator of the territory, reflects on future perspectives as the program evolves and expands: “We think that later on we will also be able to connect through this system multiple healthcare facilities, both within Nagorno-Karabakh and in other countries, involving different remote specialists. If we succeed with this program, and I am quite sure we will, then the system will ultimately expand to our regional rural hospitals in a multi-level network, connecting them both to centers in Stepanakert, in Yerevan, and via those connections – also to international medical community. Furthermore, we intend to use telemedicine systems also in our emergency medical service, providing ambulances with connection to hospitals and clinics, since in emergency situations it is especially valuable and often life-saving to have specialist’s opinion on-site. Thus, I think the program will provide us with unprecedented opportunities to improve our healthcare system, and first and foremost will allow us to better, more effectively, more professionally serve our population’s healthcare needs”.
Much of the success of that program will be contingent on the ability of local authorities to secure reliable and affordable high-speed internet connection throughout the region. The monopolist local internet service provider, Karabakh Telecom company, has fairly developed infrastructure delivering also broadband connectivity to considerable number of locations throughout the region. At the same time, there is almost no wireless service installed. Local mobile telephony is limited to 2G network, which considerably restricts connectivity options. The major Armenian fiber optic provider, GNC is planning to extend its backbone to reach Nagorno-Karabakh in early 2011, which will significantly improve the broadband landscape in the region. By far the most important prohibitive factor is the cost of high speed connection, which is currently few times that in mainland Armenia. Local regulatory bodies are currently leveraging the pricing policy of the company, to make broadband more affordable and thus make possible sustainable development of telehealth in the area.
AATM team is determined to do their best to bring the long-suffering people of Nagorno-Karabakh modern Health ICT tools capable of revolutionizing healthcare delivery in the country.
We would like to express gratitude to our partners and collaborators, as well as to local organizers, referring physicians and consultants, internet providers, and all those who contributed to the project, wishing everyone Happy Holidays and Healthy and Prosperous New Year of 2011.