Studija o potencijalima primene telemedicine u Srbiji i njenim benefitima za građane i lokalne samouprave. Study on the potentials of implementation of telemedicine in Serbia and its benefits for the citizens and local governments.

1. Summary of the Results of the Study
POTENTIAL BENEFITS OF THE APPLICATION OF TELEMEDICINE IN SERBIA
Based on Master Thesis
Submitted to the Faculty
of
American Public University
by
Volha Skarin
In Partial Fulfillment of the
Requirements for the Degree
of
Master of Public Health
February 2016
American Public University
Charles Town, WV

2. FINDINGS OF THE STUDY
 Currently among many important healthcare priorities in Serbia, none of them include
development of telemedicine.
 All study participants characterized the current status of telemedicine in Serbia as non-
existent.
 Study participants, who have had personal experience with telemedicine projects,
reported positive results.
 All international telemedicine projects were stopped and not maintained after the end of
the project and exhausted financial support.
 Majority of study participants agreed that health interventions, such as telemedicine, are
normally initiated and funded by enthusiastic individuals.
 No one reported spillover effect or interest and support from higher authorities.
 Over 93% of respondents named "Consultation with a specialist" as a greatest potential
benefit of telemedicine in Serbia (see Table 1 for the full list of benefits).
 According to study participants, the biggest obstacles to further development of
telemedicine in Serbia are lack of technical capacity/availability of necessary equipment
and fear/resistance to new technologies especially among older generation of doctors
(see Table 2 for the full list of obstacles).
 Healthcare providers are the main actors who are interested, but also who may be
opposed to the development of telemedicine in Serbia (see Table 3).
 The main motivational factor for participation in telemedicine projects was enthusiasm of
healthcare providers (see Figure 1 for the full list of motivational factors).

3.  The enthusiasm of individuals, who understand the technologies and want to improve
existing system, was the most popular response to the question of what factors are
necessary for the sustainable development of telemedicine (see Table 4 for other factors).
 Over 66% of respondents think that support of the law, inclusion of teleconsultations as
the official job requirement, and education about telemedicine and its benefits are very
important for future development.
 Over half of all respondents believe that without support from the Ministry of Health the
development of telemedicine in Serbia cannot be sustainable.

4. TABLES AND FIGURES
Table 1.
Potential benefits of telemedicine in Serbia, results of 2015 telemedicine research
POTENTIAL BENEFITS (n=15) Number of
Responses*
Allows consultation with a specialist
Saves time
Eliminates the need to travel and travel expenses
Allows possibility for obtaining second opinion
Offers services in hard to reach areas
Offers educational opportunities
Cheap diagnostic equipment
Allows effective use of resources (personnel and equipment)
Improved the quality of healthcare
Allows convenient access to patient information
Provides safety to patients in critical conditions
Provides opportunity to receive diagnosis faster
Saves money for the budget
Relives the burden from regional healthcare centers
Improves triage of the patients
Improves the equality in access to healthcare
Available any time
Limits number of mistakes
Provides the opportunity to conduct large studies
14
10
9
8
8
8
7
7
7
6
6
5
4
3
3
2
2
1
1
*Multiple responses were allowed
Table 2.
Barriers to telemedicine development in Serbia, results of 2015 telemedicine research
BARRIERS (n=15)
Number of
responses*
Lack of technical capacity (necessary equipment) 10
Fear/resistance of new technologies 9
Lack of knowledge about the benefits of telemedicine among stakeholders 7
Limited financial resources 7
Not supported by law/ not part of healthcare system 6
Resistance to changes/preference for conservative way of providing services 6
Poor organization, no connection between the providers 6
Lack of support from the Ministry of Health 5
For already busy doctors telemedicine consultations are additional work 4
Lack of possibility to be reimbursed for providing teleconsultations 4
Corruption/not transparent government 3
Electronic records and signatures are not recognized 3

5. Telemedicine software is not adopted to the need of medical providers 2
Inconvenient location/poor access to telemedicine equipment 2
Confidentiality/privacy concerns 1
*Multiple responses were allowed
Table 3.
Key actors interested and opposed to development of telemedicine, results of 2015 telemedicine
research
Ministry
of Health
Health
Insurance
Fund
Public
Health
System
Healthcare
Providers
Patients Private
sector
Municipality
Interested n=4 n=4 n=3 n=10 n=6 n=1 n=1
Opposed n=1 n=10 n=1
Note: n-number of times the actor was mentioned. One respondent could mention more than one actor.
Figure 1. Incentives that motivated healthcare providers to participate in telemedicine projects
(n=15). Results of 2015 telemedicine research.
9
6
6
5
4
3
0 1 2 3 4 5 6 7 8 9 10
Enthusiasm of provider
Understanding the benefits
Professional/educational development
Order from superiors/motivated head of the
department
Improvement of working conditions/TM makes
work easier
Desire to help patients in a most effective way

6. Table 4.
Factors necessary for sustainable development of telemedicine in Serbia, results of 2015
telemedicine research
NECESSARY FACTORS (n=15)
Number of
responses*
Enthusiasm of people, who want to improve existing system 11
Provide education (through media campaign n=4) about telemedicine and
its benefits to all stakeholders
10
Support of the law 10
Make teleconsultations a job requirement 10
Money is not crucial, but it is important to compensate specialist for
additional work and qualifications
8
Funding 8
Make telemedicine part of official healthcare system 8
Make telemedicine part of integrated health information system 7
Share with public experience of other countries 6
Clear distribution of responsibilities in the system 6
Support of respected doctors 6
Support of the Ministry of Health 5
Connect all interested medical providers in one network 5
Recognition of telemedicine in budget 5
Purchasing of all necessary equipment 5
Recognize telemedicine as a priority 4
Accept electronic prescriptions and record keeping 4
Create team for promotion of telemedicine 3
Provide technical and computer training to medical providers 3
Include teleconsultations in list of services reimbursed by Health Insurance
Fund
3
Investment in well established Internet connection 3
First meet most basic needs before developing telemedicine 3
Adopt IT technologies to the needs of medical providers 2
Install telemedicine equipment in convenient location where it is most
needed
2
Assure data confidentiality 2
Create working discipline that will allow fully implement and maintain the
project
1
*Multiple responses were allowed

7. CONCLUSIONS
Discussion
Despite several attempts to develop telemedicine in Serbia by enthusiastic individuals
and non-governmental organizations, telemedicine status in Serbia may be described as non-
existent.
This study provides some evidence that the development of telemedicine in Serbia,
however, may offer many potential benefits. In the country, where the distribution of medical
facilities and personnel is not even, many areas without adequate access to quality healthcare can
benefit from teleconsultations with specialists. Teleconsultations, organized at patient's local
medical facility, eliminate the need to travel to bigger cities hours away from home, saving
patients time and money. At the same time, teleconsultations provide safety to patients in critical
condition, who face serious risks to health and life if required to travel to secondary or tertiary
medical facility in fragile condition, or traveling in dangerous weather circumstances. A number
of interviewed medical providers said that they could greatly benefit from education they receive
through teletechnologies. For example, while specialists receive the opportunity to observe
online, real time complex surgical procedures, local general practitioners can learn from the
specialists during teleconsultations they organize for their patients.
Unfortunately the list of obstacles for the development of telemedicine in Serbia is
significant. One of the most serious barriers named by study participants is the technological
capacity. Reasonably, without support from the official system and their funding, even cheap
telemedicine equipment cannot be purchased. Another problem is fear and resistance to new
technologies especially among older generation of doctors. Another significant barrier to
telemedicine development is lack of information about telemedicine and its benefits. Four

8. respondents said that inability to get reimbursed for teleconsultations is a great restraint for
medical providers to participate in them. However, this restraint was eliminated in 2013, when
the services provided via telephone or Internet were included in the list of medical services
reimbursed by the National Health Insurance Fund. The list of codes used to bill the Insurance
Fund includes the description of eHealth services. They include individual medico-educational
service, preventive advice, consultation of individuals at the medical facility, planned meetings
and discussions, as well as maintaining of records and medically related documentation
(National Health Insurance Fund, n.d.). Regretfully, only one study participant knew about the
possibility to charge the Insurance Fund for teleconsultations.
With regards to key actors and interested stakeholders, healthcare providers turned out to
be the party that is most interested and at the same time most likely oppose the development of
telemedicine. Assuming that they appreciate the benefits of telemedicine, they may fear
computers and new technologies. They rather use limited resources to fix more important, in
their opinion, issues, before investing in telemedicine projects.
Those, who had experience with telemedicine, were excited and enthusiastic to
participate in the project because they were well aware of the benefits telemedicine can offer
them and their patients. In fact, enthusiasm was number one motivator and factor necessary for
further development of telemedicine in Serbia. However, without legal base, inclusion of
telemedicine services in official healthcare system, financial support from the Ministry of Health
and Health Insurance Fund, enthusiasm quickly wears out, leaving even successful projects no
chance for survival. It supports the hypothesis of this paper that: If telemedicine is integrated into
Serbia's national health care strategy, then it will be widely adopted by health care providers,
resulting in significant economic and health benefits.

9. Recommendations
Based on the results of this research, several recommendations can be made:
 Include telemedicine in the national health care strategy, asking healthcare providers to
perform teleconsultations as part of their job
 Create promotion team that will be responsible for distribution of information about
telemedicine, its benefits to Serbia, and examples from other countries though media
campaigns
 Assure support from the heads of medical facilities and departments, and respected
doctors, whose authority is important to younger doctors
 Provide telemedicine and computer training to healthcare providers, who lack such
education
 Conduct research to find out which areas may be in greater need for telemedicine
development. Provide them with equipment and support first
 Connect medical providers in one network, which will enable them receive and provide
telemedicine services
 Improve health information system, which will unable electronic record keeping,
signature, and possibility to write prescriptions
 Inform healthcare providers about the reimbursement for eHealth services by the Health
Insurance Fund
 After the inclusion in healthcare system, it may be useful to conduct research to find out
how the law impacted adoption and development of telemedicine in Serbia. This
information may be essential for the development of future health interventions in this
country.