>> With regard to digitalization, the initial situation in healthcare is deficient, and this also affects the hospital sector, the editors state in the introduction to the “Hospital Report 2019” (eds. Jürgen Klauber, Max Geraedts, Jörg Friedrich, Jürgen Wasem/SpringerOpen , 359 pages). For the current report, they have decided to take a closer look at the status of digitalization in German hospitals and the associated challenges.
The book is divided into three parts. The first part is dedicated to the question of how the use of hospital IT compares internationally and what conditions are required for more extensive use in hospitals. Further questions include: How are medical careers changing? What about the electronic patient record? And how does digital transformation in hospitals ultimately affect patient care? The investment requirements and financial requirements for digitalization are also taken into account.
In the second part, entitled “For Discussion”, an article using emergency centers as an example makes it clear how care can be planned on the basis of data-based market space analyses. Further subchapters examine the opportunities of digitalization for health services research and put the recording of hospital investments in Germany to the test.
The last, third part of the report contains extensive statistics with detailed evaluations based on data from the Federal Statistical Office and the AOK Scientific Institute (WIdO). There is also an overview of key indicators for more than 1,400 hospitals - based on structure, range of services, competitive situation and quality.
So what does the digitalization of German hospitals look like? Digitization is only slowly making its way into German hospitals, is the conclusion of Victor Stephani, Reinhard Busse and Alexander Geissler (“Benchmarking hospital IT: Germany in an international comparison”). The proportion of hospitals that do not yet or hardly work digitally in the clinical area (level 0 EMRAM, for the EMRAM level model see page 23) is 40 percent in Germany. Other countries are much further along here; in Turkey the proportion is around 7 percent. “Many useful IT applications that are more common in other countries are not yet used in this country,” says the report.
Hospitals must learn the ABCs of digitalization
This can be clearly seen using the example of the IT-supported, closed medication cycle - which is intended to prevent human-caused errors in the medication process and thereby improve the quality of care in hospitals: “In Germany, only 1 percent of clinics have this, in the USA already over 40 percent.” The electronic patient file, a central element of digitalization, is also not yet available in German hospitals to the extent that could actually be assumed. If anything, so-called clinical data repositories (level 2 EMRAM) would be used in this country, just a preliminary stage of the EHR, in which parts of the patient file are available digitally, but important functions are missing, such as the electronic fever curve.
The authors also complain that digital communication with external actors, such as telemedicine services, has not become as widespread in recent years as would seem natural today. One of the reasons they see for this is the poor technical interoperability and the sluggish broadband expansion in Germany. “A better basis must be created here in the future so that this area can be expanded more intensively,” they demand. In addition to technical interoperability, syntactic interoperability must also be further promoted in the future, for example through the standardization of the doctor's letter. This is the only way to ensure a smooth, digital exchange of clinical information between hospitals and other players. It is therefore important that achievable goals are defined and the available resources are used sensibly. Clinical decision support based on deep learning algorithms can only be used once the patient data is available digitally.
To do this, a hospital must master the “ABCs of digitalization”. For example, care robots that are able to meaningfully relieve the burden on nursing staff in appropriate places could only work if they were adapted to the local context, the processes were coordinated and the staff were trained accordingly. Otherwise, their use will lead to frustration, skepticism and doubts about the benefits of digitalization. As a result, everything would remain the same while the world outside the hospital changes, the warning goes.
“If hospitals fail to create the conditions for the use of such new technologies in the future, this could lead to them being used informally,” the authors suspect. Digital services are already being used for communication between doctors or privately created patient databases are being maintained on smartphones. However, in their opinion, such “informal” solutions carry a high risk, especially with regard to data protection. “It is up to the hospitals to offer central solutions that meet the requirements and to help steer and control the change,” is their summary.
“Only when the very large majority of healthcare providers are digitally connected (infrastructure), when they can exchange data (interoperability), when this data is used for process control (clinical information logistics) and for knowledge generation (data analytics) will digitalization have achieved its purpose .” This is the assumption of the authors of the article “State of digitalization and the use of technology in German hospitals” (Ursula Hübner, Jan-David Liebe, Moritz Esdar, Jens Hüsers, Jens Rauch. Johannes Thye and Jan-Patrick Weiß).
But they don't just criticize, they also point to a positive example - the BMBF's medical informatics initiative as a “good approach to building lighthouses”. However, there is a lack of focus on widespread application beyond science. So far, politics in Germany has not had any influence with measurable consequences. Although there are different political ideas about the design of digitalization and eHealth in the federal states, this cannot be determined based on the adjusted key figures (Workflow Composite Score and Telemed Score). The effects of the coalition agreement, the declaration of the 90th Conference of Health Ministers and the eHealth Act are still unclear. Ultimately, digitalization in the healthcare system is not the sole concern of the Ministry of Health, but is framed by the concerns of the Ministry of Education and Research and the Ministry of Economic Affairs. “If you look closely at the word digitalization, it is the noun of digitalize, i.e. a verb that suggests a process. This is also how the noun should be understood. It is important that this process maintains momentum and leads to measurable successes,” the authors appeal.
As a concrete example of the use of digital data in care planning, Boris Augurzky, Andreas Beivers, Philipp Breidenbach, Alexander Haering and Niels Straub (“Supply planning through data-based market space analyzes using the example of emergency centers”) look at emergency care in Germany. They use simulation analyzes to help ensure comprehensive accessibility of emergency centers.
Current emergency care has a variety of problems and inefficiencies. So-called emergency centers are intended to improve the cross-sector, patient-oriented coordination of care structures. As part of simulation analyzes - created by the RWI on behalf of the National Association of Statutory Health Insurance Physicians - two different model approaches were used to determine the necessary minimum number of such emergency centers: “Greenfield” and “Real Locations”. In the former case, the required centers were distributed “freely” from currently existing locations in Germany, so that a maximum distance of 30 minutes' drive to the nearest provider is given for 99.0 percent of the population. 337 centers were necessary for this.
In the second approach, the existing hospital structure in Germany was explicitly taken into account when distributing the centers, the authors explain and explain: “This means that potential centers are only located at existing hospitals that participate in emergency care.” Here it is Accessibility level of a maximum of 30 minutes travel time has been achieved for 99.6 percent of the population with 736 emergency centers. In both approaches, the number is far below the 1,456 somatic hospitals that officially took part in emergency care in 2014.
According to the authors, the simulation results made it clear “that from an economic and supply-related perspective it is not efficient for all 1,456 somatic hospitals currently participating in emergency care to maintain this status or to be supplemented by a KV emergency practice.” This should expressly not mean that the 337 locations based on the “greenfield” approach should be considered a guideline.
The authors see it as problematic that if the emergency providers are freely located, the hospital infrastructure that may be necessary in the background may not be available. However, a distribution of the necessary providers using the “real locations” approach shows that optimal care for the population would be possible even with just 736 locations, taking into account the necessary hospital infrastructure in the background.
By bundling emergency care at locations that are technically required, advantages in care could also be reaped by concentrating the provision of services, the authors note. The G-BA's specifications for the emergency level concept will significantly reduce the number of locations participating in emergency care. It remains to be seen to what extent the spatial distribution of the remaining emergency locations corresponds to the optimized distribution results. In a next step, a new simulation would be aimed at based on the remaining locations that at least meet the requirements for emergency level 1, according to the article.
In addition to an optimal location of the hospitals and emergency services participating in emergency care, an improvement in patient management and clear structural specifications and responsibilities of the facilities involved are also necessary. Experiences from abroad have shown the great importance of coordination and control when primary and general medical care for low-risk emergency patients is relocated to the clinics. However, it remains the responsibility of general practitioners. Therefore, in Germany too, an optimized spatial location of emergency locations with coordinated services from the participating facilities is crucial in order to achieve needs-based and high-quality care for emergency patients.
“It must be admitted that a lot of what could be said about digitalization and some of what could be said about health care research could not be discussed here,” admits the author of another article, Philipp Storz-Pfennig, who deals with the digitalization of health care research . This includes “particularly considerations regarding data security and data protection”. It is undisputed that it is generally important to be clear about the dangers. In his opinion, these depend essentially on what intentions and goals are pursued with the use of data.
“If, for example, the 'medical file' is shown to be crucial for justifying a medical measure, access to such medical records for health care research should mean that one hopes to recognize general principles here,” he said. “Whether the 'medical records' typically and systematically contain the information that can be used to justify an intervention?” asks the author. In any case, such analyzes do not mean that insights into individual cases are intended to be used in any way - “which is probably the goal of practically all large companies in the digitalization industry.”
The problem can be discussed productively here on the basis of the distinction between generalized, scientific knowledge and knowledge about individual cases. The task of implementing technical security remains the same anyway. The improving influence that one hopes for the future from scientific knowledge is fundamentally one that can be based on general laws that are found through scientific research.
“One can consider this to be naive, both in terms of the theory of science and in practice - and that is often the case with such an application-oriented science as health services research. However, a return to fundamental scientific principles seems necessary, especially when it comes to digitization aspects,” demands Storz-Pfennig. It appears that relevant parts of health services research take such challenges seriously as such. Many forms of digitization (or at least the central use of data) seemed to indicate a departure from another fundamental scientific principle: a distance from practice.
Although this is generally comparatively low in health services research, it is a key driver of the “success model” of modern science in general - also in terms of its usefulness. Health services research should also not be too interested in a specific outcome of the results. The fact that the implementation of such a principle, especially in biomedicine, is by no means easy is shown not least by the debate about waste in the sciences. The author believes that attempts should be made to gain or regain such a distance from practice. “The really interesting thing about the digitalization of care (and health care research) is that with its help it should be possible to get closer to the reality of care than before, once the distance has been established.” appears promising in terms of knowledge gains, the reason is that this goal has not yet been achieved, even with the help of the attempts that have already taken place and continued (quality transparency, evidence-based, etc.).
“In some places, the clothes of medicine still appear to be more densely woven than they actually are.” The biomedical innovation industry, the inherited idea of scientific success, the expectation of healing or relief beyond what can actually be achieved and, last but not least, the promise of comprehensive solidarity On the one hand, burden-bearing acts together to obscure, on the one hand, what is actually being or can be achieved.
Even if digital applications are structurally overrated in terms of their usefulness and are therefore part of the problem, they could also serve to educate, like previous scientific-critical approaches. Because the latter were by no means completely unsuccessful. “Overall, it should therefore also be considered whether the often complained slowness of the introduction of digital applications does not also have something to do with the - at least according to the image conveyed - considerable penetration of scientifically justified practice in healthcare and thus the measurement
“The bar for transformations and disruptions is much higher than elsewhere,” the author concludes. <<
Author: Olga Gilbers
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