A year ago, mass internet outages began in Russia. The problem affected dozens of regions, with residents of Central Russia, the Volga region, and border areas reporting outages most frequently. In July of last year, Russia set its first world record for the number of shutdowns – over two thousand outages – exceeding the global figure tenfold. It quickly became clear that the problems also affected healthcare. Patients with diabetes were the first to feel it – applications used to send glucose monitoring data to smartphones did not work without the internet. This meant it was impossible to monitor blood sugar levels, a vital indicator. According to a survey conducted by the "Doctor's Handbook" app among its users, mobile internet outages at work have become a regular problem for 54% of medical professionals. Some noted that wired internet was not provided in their facility, so mobile internet outages practically stopped work. Without the internet, it is often impossible to clarify information about a medication, upload patient data to the system, or even – seemingly – take a blood sample. Doctors told "Novaya-Europe" how they are working under conditions of endless shutdowns. All names have been changed at their request. Photo: Maxim Shipenkov / EPA. Working manually, Irina has been working in an ambulance crew in Moscow since the pandemic. According to her, this service is now fully digitized. After a patient's call, the dispatcher enters the data into a unified electronic database, and from there, calls are distributed to ambulance crews. Calls come to a tablet, which is integrated with EMIAС (unified medical digital system) and is available to every ambulance doctor. This device replaces all the paperwork that had to be done before. Through the tablet, the doctor can obtain operational data about the patient, make prescriptions, and transfer accompanying documents to the hospital. – In May, it became impossible to respond to calls, – complains Irina. – In the "trekhka" area, the internet consistently disappeared – and then you figure it out. The driver gets angry because it's unclear how to drive. Because of this, we sometimes wandered through courtyards before finally reaching the right house. The tablet worked partially: the call, thank God, comes through, although sometimes with a delay, but you can't access the patient's card. And this is important because the dispatcher's initial information is always very general – just age and what happened. Usually, while driving, you look at the card to see if there are chronic diseases, drug allergies, or other nuances. And during the appointment, you don't waste time asking questions. But when the internet is down, you drive to the patient with no idea about them. " And here I sit, asking questions, although all the answers are in the medical record, only it's inaccessible. All this lengthens the appointment time, and for an ambulance, it's critical. Then, while shaking in the car on the way to the next call, you write down the diagnosis, recommendations, and prescriptions on paper as before, so as not to forget. And in the evening, you enter it into the computer. According to Irina, there is a special helper application for the ambulance, where you can see diagnosis codes and clarify the algorithm of actions. You enter the diagnosis – and it immediately shows whether hospitalization is needed and where to take the patient. It can be downloaded in advance to work without the internet. Otherwise, even more time would be spent on the call, not on examining the patient, but on some organizational matters. Nevertheless, questions can still arise – about medication prescriptions or hospitalization – which, with internet access, can be clarified through the same tablet. – You have to call the substation by phone, – says Irina. – Or we bring the patient to the hospital, give the information verbally, and then after work, we enter everything into the system again. It's only worse for doctors on voluntary medical insurance (a paid alternative to state emergency medical services, which allows you to call a commercial team and, if necessary, be hospitalized in a private clinic. – Editorial note). Their application does not work without a network. Receiving calls, routing patients, requesting hospitalization – everything has to be done through the dispatcher. He calls the doctor back and explains the procedure. In general, the last century instead of digital medicine. Everything is turned off Today, almost all state medical institutions work with information systems. The programs may vary, but the essence is the same: they unite all the work of the polyclinic – electronic registration, referrals to specialists, laboratory tests, prescriptions, hospital discharge summaries – into a single digital database. Doctors have complained about the operation of these systems before – the program sometimes freezes, sometimes glitches, and now problems with the internet have been added to its imperfections. Anna is a paramedic at a district polyclinic in the Volgograd region. Internet outages began constantly here back last year. Residents are already used to the network disappearing in the evening, and it's usually gone by morning. But there are regular interruptions during the day as well. – At first, when the internet was turned off, we had chaos, – says Anna. – The district doctor can't do without it: the computer contains the history of doctor visits, specialist appointments, and hospital discharge summaries. We can check test results, prescriptions there. We couldn't even take blood samples from patients because without the internet, you can't create a barcode for the tube. Now, according to Anna, all medical information is being duplicated on paper. – But you still can't cover all cases, – she admits. – I was recently filling out a sick leave form, and everything turned off. The next day I look, and it's not in the system, as if I hadn't entered anything. Or here's a common situation: you're filling out a chart, the internet disappears – all the information is lost, and you have to re-enter everything. And sometimes there's no connection at all, not even by phone. " The other day, a patient came for an appointment, and he needed to be hospitalized. The doctor called the hospital, but the call didn't go through. Oh, how nervous we were. Fortunately, after about ten minutes, the connection returned, and everything was fine. Photo: Anton Vergun / TASS / Zuma Press / Scanpix / LETA. Out of reach. Doctors themselves consider the lack of access to professional information to be the biggest problem associated with internet outages. – Look, I have an oncology patient at my appointment, and I need to prescribe medication, and I need to quickly clarify the dosage according to the protocol, – says Roman, an oncologist at a private clinic in Moscow. – Or look at the current guideline, but the resource is either unavailable or requires a subscription that cannot be obtained without a foreign card. I have to work from memory, it's uncomfortable. I often read outrage in chats: what kind of doctor are you if you can't write a prescription without the internet. But no specialist can keep all the information in their head, so it will be limited. His colleague is supported by Evgeny, an ophthalmologist from a Moscow hospital. – I remember the dosages and how to take medications that I prescribe regularly by heart. For everything else, there's the internet. Or rather, there was. Recently, a patient came for an appointment who had complications after starting a medication. I had never encountered this before, and I needed to urgently review the literature and find a replacement. Foreign websites are blocked here, but a VPN can help with that. But if there's no internet at all – neither mobile nor Wi-Fi in the polyclinic – what can I do? Only offer to come back later or see another, more experienced doctor. For Olga, a psychiatrist from Samara, such situations are more the exception than the rule. – Of course, mobile internet disappears constantly in our city, but the clinic has its own Wi-Fi, which is usually enough to conduct appointments, – she says. – Although once there was a situation: I had a patient with a co-existing chronic illness, and I needed to clarify the combination of medications and dosage. And the internet had been lagging since morning, nothing was loading. I told the patient that as soon as I found out, I would call him back. According to the doctor, such a situation, although unpleasant, is solvable. It is much more critical that internet outages affect the ability to learn. – I constantly take training courses, listen to lectures, attend online conferences. And all this takes place on platforms like Zoom and Yandex Telemost, which require a stable internet connection. And this is precisely the problem. Either the picture freezes, or you can't log into the platform at all. The other day I was at an online conference on child behavioral disorders, my internet froze, and I was kicked out of the lecture. And it wasn't recorded. That's a shame! Photo: Yuri Smityuk / TASS / Zuma Press / Scanpix / LETA. Double work After the incident where she couldn't quickly get online to find a medication, Olga decided to play it safe. She made a reminder in a Word document with the dosages of all the medications she usually prescribes. She downloaded tests and questionnaires for diagnosis to her computer, which she usually used online. – Medications are one thing, you can indeed call back. But if everything freezes while the patient is taking a test, it will look bad, – explains Olga. – So I "covered myself" in advance. Most doctors are forced to do the same – to back up virtually every stage of their work. – Everything I use on a regular basis, I now have in an offline version, – says ophthalmologist Evgeny. – Treatment regimens, dosages, the Amsler grid test, which helps detect problems in the central parts of the retina, disease coding – all of this I used to find on websites with one mouse click. Now everything is saved in folders on my computer's desktop. " But it's impossible to predict what might be needed at any given appointment, so a doctor is internally always prepared for the fact that they may not be able to provide full assistance. Paperwork has also increased. Without the internet, even consent for the transfer of personal data cannot be filled out online; patients have to write it by hand. – We always had a lot of writing. Even with the internet, we have to fill out a lot of things, but at least not by hand. And now we issue both an electronic and a paper referral. So that the patient can get to a specialist if there is no internet. First, everyone re-learned how to write electronic prescriptions, and now we are teaching young people to write paper ones again, – chuckles paramedic Anna sadly.