Telemedicine in the context of accessibility of medical aid in Russia

The urgency of the topic is determined by the need to signifi cantly increase the level of accessibility of medical services, fi rst of all — of an innovative nature. The purpose of the article is to identify and characterize the development of telemedicine in contemporary Russia and therefore, propose the tools to improve accessibility of telemedicine services to the population.. Management decisions and organizational and economic relations that arise within the development of telemedicine are the subject of the study. The main results are: analysis of accessibility of medical services to the population as a whole was conducted; directions of using telemedicine technologies as an instrument for increasing access to medical care were identifi ed; problems in the development of the domestic telemedicine market were outlined; diff erentiated accessibility of telemedicine services by diff erent criteria were identifi ed; directions for solving identifi ed problems were suggested. The author suggests development of network cooperation between medical prevention centers, telemedicine centers and educational institutions located in rural areas. The materials of the article can be useful both for further scientifi c substantiation of ways for development of healthcare and for elaboration of practical solutions for the development of the market of innovative medical services.


Introduction
The high pace of changes in the external environment necessitates the development, careful substantiation and rapid implementation of innovative solutions. To the fullest extent, this applies to social organizations, a large-scale component of which is the area of medical services.
At the same time, recent studies in the fi eld of development of medicine and public health in general [Popovich et al., 2014: 156-169] enable stating the presence of a paradox of innovations: on the one hand, innovative solutions enable improving the quality of medical services and the capacity of the health care system to meet the needs of the population, and on the other, they predetermine the growth of spending on health. In this regard, the issue of accessibility of innovative medical services for the population in Russia becomes ever more topical.
Since telemedicine is one of the most relevant and socially signifi cant areas of innovative development of the healthcare area, the goal of this study is to identify and characterize development of telemedicine services in the Russian reality, and to off er instruments to increase their accessibility to the population. The objectives of the study are to analyze the accessibility of medical services to the population, to identify the directions for using telemedicine technologies as an instrument to increase the availability of medical care, to identify problems in the development of the national telemedicine market, to diff erentiate the accessibility of telemedicine services by various criteria, and to suggest solutions to the identifi ed problems.

Review of scientific sources
The existing problems of the healthcare system in Russia, the lessons of the healthcare reform and the challenges for the industry in the coming decades are revealed in the works of N. A. Voskolovich and M. Y. Sheresheva [Voskolovich, 2014, Sheresheva., 2017. Comparative studies of healthcare reforms in countries that represent diff erent models of organization and fi nancing of healthcare are

Methodology
The principle method in the study of this issue is the analytical method. Based on the analysis of the current legislative base, the materials of the Federal Service for State Statistics of the Russian Federation (data from the Comprehensive Observation of Living Conditions of the Population -COLCP -and statistical yearbooks), as well as the publications of leading researchers on issues related to the availability of medical services to the population, the author's own point of view on the issues and diff erentiation of accessibility of telemedicine services was determined. As a result, conclusions are drawn and possible directions for solving the identifi ed problems are outlined. The materials of the article can be used as recommendations for the development of scientifi c substantiation and practical solutions for the development of the market of innovative medical services.

Research results
The state of the Russian healthcare system can now be characterized as extremely problematic. The macroeconomic situation of the past years and the defi cit of the state budget predetermined a relatively low, when compared to developed countries, level of state fi nancing of the healthcare system  Against the background of a general decrease in the availability of services of healthcare organizations, morbidity of the population is increasing. According to the above mentioned COLCP-2016, 55.7% of respondents (in rural areasmore than 60%) assessed the state of their health from "satisfactory" to "very poor" (Fig. 2). At the same time, a quarter of respondents suff er from chronic diseases (the prevalence of chronic diseases is 26.2%).
Under these conditions, the development of telemedicine technologies can be considered as an instrument to reduce the severity of these problems. tele-guidance and tele-tution; remote examination; telemedical dynamic monitoring of patients' health; telesurgery, etc. The volume of the telemedicine services market is growing rapidly throughout the world. By 2019, the global telemedicine market will reach almost $44 billion, showing an average annual growth of 17.7%. At the same time, the US telemedicine market is growing at an average rate of 67% per year -in 2018 it is to reach $3.5 billion, with the number of online of 7.1 million people (in 2012 there were 344 thousand) [Upatov, 2015].
Russia should not be an exception in this process. So, in the implementation of the priority project "Improving the processes of organization of medical care based on the introduction of information technologies" for 2016-2025, approved by the Presidium of the Presidential Council for Strategic Development and Priority Projects on October 25, 2016, the proclaimed target indicator is improvement of medical assistance to citizens via: implementation of information technologies, monitoring the possibility of recording a doctor's appointment, transition to management of medical records in digital form of at least 80% by 2020, performance of at least 10 digital services via a patient's personal online "My Health" account on the Unifi ed Public Services Portal (UPSP), which will be used by at least 30 million citizens in 2020. In the end, the number of administrative regions of the Russian Federation, where the processes of rendering medical assistance using telemedicine technologies are organized, should increase from 7 (in 2017) to 85 (in 2025) [Passport of Priority Project..., 2016].
However, today we can state the presence of a number of problems that hamper the development of the national telemedicine market. Among them, undoubtedly, are insuffi cient legislative support for the development of the telemedicine market (the legal and regulatory framework is only at the stage of formation), and lack of competence of medical specialists in the fi eld of telemedicine.
The problem of low economic and physical (technical) accessibility of telecommunication technologies to the population is a particular challenge. Obviously, telemedicine services, even if provided free of charge, require the availability of special devices, a stable Internet connection, etc., which under the conditions of impoverishment (Fig. 3) is a signifi cant limitation for many potential consumers from remote areas. Another problem is the gerontological accessibility of telemedicine services. According to the COLCP-2016, among persons over the working age, only 35.5% of respondents have access to the Internet (in rural areas -24.3%), whereas the average fi gure (for persons aged 15 and more) is twice as high -70.9% (Fig. 4).
Similar is the situation with the "availability of skills for practical work with a personal computer" indicator -in general it is equal to 70.1%, while for people older than working age it is twice lower -33.3% (in rural areas -22, 2%) (Fig. 5). Doubtlessly, the presence of computing skills is primarily necessary for medical personnel, however, the specifi cs of telemedicine services call for the necessity of certain patient competence ("computing literacy") in acquiring these services.

Conclusions and recommendations
The study shows that the availability of telemedicine services is much lower for residents of rural areas and for elderly people in comparison if the rest of population.
The priority direction of action to provide improved healthcare services is the development of the system of preventive activities; therefore, it is crucially important to use the abilities of telemedicine to provide population with prophylactic medical services, including consultations. Thereupon, within the framework of resolving the above stated problems, we consider it expedient to develop network cooperation among structures such as medical prevention centers and telemedicine centers with educational institutions, primarily those located in rural areas (Fig. 6).

Medical organizations Telemedicine Centers Centers for Medical Prevention
Realization of additional educational programs on medical prevention for the rural population Currently, medical organizations interact with centers for medical prevention and telemedicine centers. They exist in each region, but are concentrated, as a rule, in regional and republican centers. Accordingly, their services, including those for preventive medicine, are more accessible to urban residents. Rural residents, for already mentioned reasons, are less able to use them.
In rural areas, at least in district centers, signifi cant opportunities for the use of telecommunications technologies (the availability of computers, multimedia equipment, access to the Internet) exist in the educational organizations.
We suppose that network interaction should be manifested in the organization on a regular basis of videoconferences, webinars and other information and educational events as a form of preventive medical services in small groups in the form of additional educational programs. In fact, this means the "Doctor-Patient" option.
Currently, such projects are being implemented on television; there are specialized sites on the Internet, but they either do not have online feedback, or are inaccessible for the above mentioned reasons.