The IT implementation of selective contracts

The selective contracts according to §73b, c SGB V aim to improve the quality of outpatient care and at the same time exploit economic reserves. By creating the possibility of concluding selective contracts, the legislature aimed to enable direct negotiations between health insurance companies and medical groups to agree on specific quality goals in terms of care and cost-effectiveness. Achieving this requires changes to the way practices work. These changes can only be implemented effectively and without affecting everyday practice if appropriate tools actively support doctors and medical professionals. Only through practice IT that reflects the contractual goals and is deeply integrated into the practice processes are the contracted doctors able to fulfill the agreements and thus justify the claim to more appropriate remuneration for their services. Following this finding, the contracting parties to the HzV and FaV contracts concluded so far have agreed to specifically define the requirements for contract software and to declare the use of contract software as a condition of participation. In the meantime, initial experiences have been gained based on the selective contracts concluded (in particular the contracts of the General Practitioner Contract Association eG and the MEDI Association), which will be reported on below.

>> With the introduction of the KVK in 1994, medical practices began to be equipped more comprehensively with IT. In 2000, over 90 percent of all practicing doctors had a practice IT system approved by the KBV, often also called “practice software” or “doctor information system”. The supply side for these systems is subject to the free market; The KBV regulates access to this market through certification requirements that a provider must meet so that their system can be used to bill statutory health insurance services. According to KBV statistics, there are currently over 180 systems approved in the AIS market. This number has been relatively constant since the mid-1990s. On closer inspection, it can be seen that CompuGroup Medical AG including TurboMed EDV GmbH (35.76% market share) and medatiXX - Medizinische Informationssysteme GmbH & Co. KG (18.03%) are the largest providers. The outpatient modules of clinical information systems are also represented in the admission statistics due to the relevance of KV billing from hospitals.
Development of the scope of services
Physician information systems
At the beginning of the development of IT systems for medical practices, the programs were limited to functionalities for printing forms, billing and documenting basic data and statistics. Today, doctor information systems represent complex solutions to support processes in the practice and offer a scope of services that goes well beyond the mandatory requirements of the KBV. Functions for the treatment and billing of private and BG patients are integrated, as are extensive drug information systems, detailed statistics and modules for structured medical documentation. The initial “billing and form printing systems” gave rise to programs that developed into complex “ERP solutions” for outpatient facilities. The planned introduction of the electronic health card and the associated establishment of a telematics infrastructure as well as the constantly increasing number of doctor networks, medical care centers and large practice groups require even more comprehensive IT support now and in the future.
In addition to the implementation of data protection requirements, the top priority here is the electronic exchange of treatment data, billing management and structured documentation that enables smooth data exchange. Particularly in the case of medical networks, there are individual requirements for each medical network: Medical networks that are just being founded usually initially focus on the exchange of treatment data. The more intensively the doctor networks work, the more extensive their service and therefore IT requirements catalog becomes. If medical networks conclude contracts with health insurance companies, the IT manufacturers must implement the registration, billing, prescription, statistics and documentation requirements of the respective contract.
The variety of offers on the AIS market (regional, specialty-specific, special solutions for large practices and MVZs, outpatient solutions, etc.) and the strong competition guarantee doctors a wide range of offers from which they can freely choose according to their individual needs.
Contents of the selective contract functions
With the start of new forms of care - whether DMP, integrated care, doctor networks or selective contracts - new requirements arose in terms of the scope of services provided by the systems. Following the logic of the gradual introduction of the HzV contracts, the scope of services of the contract software increased and continues to increase. At the beginning of every selective contract, the functions “practice registration”, “patient registration” as well as functions for billing flat-rate services and their regular checks are required. Another essential element is the functionalities for economical drug therapy: Here, for each prescription, it is checked whether the drug selected by the doctor corresponds to the agreements between the contracting parties. If this is not the case, the contract software will suggest an alternative medication. Another function is the creation of a billing file for the data center, which is sent either online (AOK Baden-Württemberg) or, for example, on CD (AOK Bayern).
Further requirements for the contract software can be found in the current specifications for long-running selective contracts. These are intended to ensure that the agreed qualitative and economic goals for the treatment of HzV patients can be identified and adhered to by the practice without major effort. Functions for a more economical drug prescription, support for the differentiated coding of diagnoses and additional recording masks, for example for a special “health status” of the patient, must be implemented - with different priorities for each contract. In the future, implementation of guidelines and further decision support and care control systems are planned to support the doctor in his diagnosis and in his decision for high-quality and at the same time economical therapy.
Parallels can be seen here with the current efforts of the KBV, which is also currently discussing an expansion of the catalog of requirements for software approved for collective contract care in the area of collective agreements.
IT implementation of new contract forms
There are various options for the IT implementation of the new contract forms:
a) Native implementation in the usual doctor information system
Since the AIS industry is already at least partially implementing the functionalities required by the new contract forms in other areas and is reacting to the requirements of its customers for purely competitive reasons, it is logical to leave the implementation of the contract functions to the providers themselves and using the strengths of one to enable a competitively organized market. As in any free market, the providers here also follow the development of the demands of their customers, who would like to manage the new contract forms with the usual ergonomics and appearance if possible.
b) Use of your own, additional contract software
Another variant is to use completely independent contract software with its own user interface. This option requires doctors to deal with additional software that is used in addition to the usual doctor information system. Patients who are treated both under a collective agreement - e.g. in the emergency service - and under a selective agreement must then be recorded twice.
With its first major HzV contract, the contract with AOK Baden-Württemberg, HÄVG eG decided at the start of the contract to declare its own contract software to be installed in parallel to the established practice software as a mandatory condition for participation in the contract. For this purpose, HÄVG founded HÄVG Software GmbH together with the company InterComponentWare AG, which developed the “Hausarzt+” software and introduced it to the market. The established AIS providers were therefore prevented from implementing the contract functions. After protests from the medical profession and a preliminary injunction under competition law against the market exclusion of the entire AIS industry, the HÄVG gave up this position and allowed all AIS providers to implement the contract functions in the established systems under certain conditions.
c) Integration of an external software component into the usual AIS
The selective contract partners offer a software component (“encapsulated core”) that must be used to implement the selective contract - without its own interface - which the AIS industry implements in its respective software. This software module contains the contract-specific regulations, particularly in the area of economical drug therapy. The encapsulated core generates substitution suggestions for drugs originally selected by the doctor from the drug regulation agreed between the contracting parties. In Baden-Württemberg, where the HzV contract is billed online with the HÄVG data center, the encapsulated core continues to handle communication with the connector, a hardware component for secure online transmission. In addition, the encapsulated core checks the accounting files for structural and logical correctness in the sense of a checking module. With the exception of the HzV contracts for Bavaria (e.g. AOK Bayern), the use of the encapsulated core from HÄVG Software GmbH is mandatory for the implementation of the contract functions from HÄVG HzV contracts in the existing programs. In addition to the license and maintenance fee for the HzV module of his AIS provider, the contracted doctor pays HÄVG Software GmbH an ongoing maintenance fee for the use of the encapsulated core in the underground of his system.

There is agreement in the AIS industry that the native implementation of the contract functions according to a) fundamentally enables faster, more ergonomic and therefore more cost-effective implementation. In some cases, the functions required by the contracting parties already exist in the existing systems; However, if the use of the encapsulated core is mandatory, these must be switched off and replaced with functions from the encapsulated core. This unnecessarily increases the development, coordination and testing effort for the contract software. The same experiences apply to the support of ongoing contract software in medical practices. Questions arise again and again in the hotlines of the AIS providers, particularly about installation and speed problems in connection with the encapsulated core; However, they have only a limited ability to influence or explain the functions of the “black box encapsulated core”.
A sensible approach to a solution is to convert the now mandatory use of the encapsulated core - which is a possibility with compromises, especially for smaller system providers with lower numbers of participants per contract, to be able to map the numerous contracts in their systems - into an optional use and to give companies, who want to implement these functions natively, a complete specification of the core functions too. This would lead to an acceleration of the development processes, a reduction in development and support costs and ultimately to lower fees for practicing physicians. Initial experiences with contract implementation outside the HÄVG environment already confirm this.
The special feature of the HzV and FaV contracts was and is that, at least theoretically, a large number of contractual partner constellations can arise and therefore the normative force of a unified specification device determined by legal mandate does not exist. The AIS industry therefore contacted the contracting parties early on through direct company contacts through its associations (VHitG, VDAP, Mittelstands-Initiative Praxis-EDV) with the aim of jointly defining the most uniform and practical specifications for the contract functions and incorporating their experiences.
The AIS industry is striving to make the specifications for the same functions uniform and to avoid different approaches. Only then will it be possible for resident doctors to continue to receive effective support in their daily work through the doctor information system they freely choose, thus ensuring medically high-quality and at the same time economical outpatient care.
A number of HÄVG's HzV contracts and a first FaV contract from the MEDI-Verbund3, which is also processed via HÄVG's IT structures, have now been implemented into IT functions. With the active support of the AIS industry, the HÄVG has established standardized framework conditions and procedures for the implementation of these functions. The particular challenge here is for both the HÄVG as the specifying body and for the AIS providers to convert the agreements available as contractual text into clear IT specifications. This requires a high degree of flexibility on both sides and a permanent, close coordination process, which is becoming increasingly better established through regular meetings and structured documents. Removing the requirement to use encapsulated core would positively impact this process.
It is currently apparent that contracting parties outside of the HÄVG and the MEDI association are making their own considerations regarding the IT implementation of the contracts, thereby increasing the risk of a heterogeneous landscape of specifications, the simultaneous implementation of which will result in unnecessarily high expenditure and ultimately a confusing range of functions in the Systems are being created that will reduce the acceptance of the contracts among doctors. This must be prevented through harmonization and the associated “depoliticization” of the specifications.
Conclusion and outlook
The introduction of selective contracts goes hand in hand with more intensive IT support to fulfill the contractual obligations entered into by the doctor. As a result, physician information systems will evolve towards medical decision support and care control systems. This development, which can be seen worldwide, will only succeed in Germany if uniform specifications based on ergonomics and practicality are available and if these can be established evenly and across the board, regardless of the respective political position of the contractual partners. Only then will doctors be able to actually accept the new forms of contract. <<

Telematics infrastructure
Definition of “telematics infrastructure” from gematik:
The term “telematics” is a combination of the words “telecommunications” and “computer science”. This involves the networking of various IT systems and, as a result, the possibility of linking information from different sources. The telematics infrastructure in the healthcare system connects the IT systems from doctor's practices, pharmacies, hospitals and health insurance companies and thus enables cross-system exchange of information.
It is a closed network of trustworthy participants - doctors, dentists, psychotherapists, hospitals, pharmacies - to which you can only gain access with a medical professional ID and health card.
The telematics infrastructure is designed to overcome existing information boundaries in healthcare. Medical confidentiality and the right to informational self-determination are guaranteed at all times.” (www.gematik.de)
For the goals of the telematics infrastructure, see also: “Health card: Telematics infrastructure for secure data exchange”, information from the Federal Ministry of Health dated June 8, 2010 (www.bmg.bund.de).