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>> The classic way to make a doctor's appointment is to call the practice by phone. Every patient has already experienced the associated limitations. Appointments can only be made during opening hours and require a free telephone line and a person in the practice who can answer the call. Digitalizing the appointment making process can overcome these limitations. This is made possible by browser-based online appointment booking systems in which the practice determines when which appointments are released for online booking and can be booked by patients using a publicly accessible online calendar with just a few clicks. Booking an appointment online has several advantages for patients and the practice: The practice can be reached around the clock to make an appointment without staff having to be on site. Every appointment booked online is one less call that the practice staff has to answer. This relieves the burden on the answering machine and saves the effort of manual appointment requests that arrive via email. This leaves more time for other important things. And access to a doctor's appointment is made much easier for the patient.
In 2011, TK initially started a one-year pilot project. 92 doctors from four disciplines in Berlin took part and offered their patients online appointment booking. A subsequent survey of doctors and patients showed that for 85 percent of patients, booking appointments online is a permanent alternative to telephone calls. 85 percent of doctors confirmed that online appointment booking makes work easier for their staff. That is why the project was established as a permanent offer “TK-ArztterminOnline” and expanded to cover all disciplines throughout Germany and regardless of the use of a specific online appointment booking system. The TK portal links to the doctors’ respective booking systems. Web interfaces have been set up with some providers that enable appointment previews. The next available appointments for doctors who use one of the aforementioned systems are already displayed on the search results page in the TK portal. This creates transparency for the user about the appointments that are still available in their city or region and makes it easier to find a suitable appointment because users do not have to click through the doctors' individual calendars.
The TK actively supports doctors in getting started with online appointment booking as part of a funding study. Anyone who commits to testing online appointment scheduling with their patients for a year and takes part in a survey about their experiences will receive funding of EUR 120 from the TK. Depending on the system and tariff, this sum can be used to partially or fully finance the costs of booking an appointment online. Evaluable questionnaires are available from 517 doctors who took part in 2013 and 2014 (response rate of 85 percent for 607 study participants in total). 49 percent found the time required to set up and configure the booking system to be “low” or “fairly low”. Another 40 percent felt the time required was “appropriate”. Two thirds (67 percent) confirm that online appointment booking was well received by their patients. 80 percent of doctors would recommend online appointment booking to their colleagues. An internal evaluation by TK also showed that 80 percent of former study participants continue to offer online appointment booking even a year after the TK funding ended. As TK's cooperation partners, various professional associations act as multipliers and promote the idea of making appointments online among their members. At the beginning of 2016, a good 3,000 doctors were listed on “TK-ArztterminOnline”. This corresponds to around two percent of practicing doctors in Germany. Despite all the successes achieved so far, there is still a long way to go before online appointment booking becomes a standard in outpatient care. The representative population survey in the TK SmartHealth Study 2016 shows what patients think about this. One in ten respondents already arranges things such as appointments or prescription requests online with their doctor's office, and 39 percent can already imagine doing so. And 83 percent believe that online communication with the doctor's office will be commonplace in ten years.
Interested doctors can find an FAQ catalog for booking appointments online and a short information film on tk.de. Together with its partners, TK will continue to work to ensure that as many insured persons as possible can communicate with their doctor's practices and make appointments in a modern way via the Internet.
People who stutter also benefit
of teletherapy
The Kassel Stuttering Therapy Institute and the TK started a telemedical care project in the speech therapy area in autumn 2014. Using teletherapy, people who stutter can receive treatment in their home environment for the first time. For this purpose, the patient and therapist interact with each other via a synchronous audio-video connection in a “virtual therapy room” via an online platform that has been specially adapted to the speech therapy requirements and enables effective, virtual meetings and training to be carried out under realistic conditions Individual or group session. In teletherapy, almost all therapy content is conveyed as in face-to-face therapy. The online modification of the individual elements and phases of the therapy takes place using appropriate technical aids (such as a headset, computer with webcam) and a specially developed online therapy platform “freach”. While teletherapy in individual sessions is characterized by focused, rigorous work on the disorder, patients can exchange ideas with other affected people in group sessions. The developed speaking fluency and therapy successes are simultaneously consolidated through the additional learning software.
This type of therapy is highly effective and sustainable for those affected. This results in numerous, so-called intangible effects that cannot be assessed in monetary terms. These include, on the one hand, reduced psychosocial stress and lower morbidity and, on the other hand, an increased quality of life. Therapy in the home environment has further advantages for the patient. The patient is better able to connect what he has learned with everyday life. The high level of self-management of the outsourced exercise components with the exercise software plays a particularly important role here. The entire therapy concept of teletherapy relies on structured aftercare and sustainable assurance of therapeutic success.
Teletherapy influences the structures and processes in the healthcare system and therefore has great potential to generate substantial cost savings while maintaining consistent quality. It is an alternative to face-to-face therapy treatment, meaning that there are no additional healthcare costs and thus serves the principle of contribution rate stability. A significant advantage of telemedicine applications is their scalability. The therapy process in the form of telepresence can also create so-called economies of scale. These are triggered by fixed cost degression, i.e. resource consumption per patient decreases because fixed costs are spread over more patients. In addition, teletherapy can bridge distances and thus ensure care in rural or structurally weak regions and thus eliminate regional differences in treatment quality. Individual advantages for patients are the maximum flexibility in terms of time and space - online therapy can be easily integrated into the everyday life of those affected: online therapy can be used to reach patients who cannot participate for time, psychological or organizational reasons.
To ensure the quality and evidence of “teletherapy for stuttering”, an effectiveness comparison of pure teletherapy and face-to-face therapy according to the “blended learning” concept was carried out as part of a prospective, controlled intervention study under the hypothesis of non-inferiority. Objective speech fluency (percentage of stuttered syllables) and the patients' subjective assessment using a validated questionnaire on psychosocial stress (OASES) were defined as study endpoints for the effectiveness comparison. The intervention study shows that teletherapy is an adequate replacement - i.e. equally effective - for face-to-face therapy. The analysis of the data before and after the intensive teletherapy phase already shows that patients benefit from teletherapy. On average, they were able to significantly reduce their speech influency. The psychosocial burden caused by stuttering, measured using the OASES, was also significantly reduced in the group.
Online programs with individual support are more effective for depression than pure human-machine communication
Online-based programs for people with mental illnesses have become increasingly popular in recent years. There is a lot of research being done on the topic internationally and now also in Germany; In addition, commercial providers have entered the market. The tenor of the numerous scientific studies is: The programs can achieve amazing effects, especially for depression and anxiety disorders. In the Netherlands and Sweden, online psychotherapy is already part of the regular care offering. The approach appears innovative and promising. But: Does such a program work in the German supply reality? Can the effects of the studies be replicated? How can data security be guaranteed? And last but not least: do those affected actually want to deal with their illness via the Internet instead of in personal contact with a therapist? In order to get to the bottom of these questions, the TK started a collaboration with the Free University of Berlin in 2013. The TK Depression Coach was created under the direction of Prof. Christine Knaevelsrud, who has been researching online therapy for many years. The program has been in pilot phase since 2014, which is scientifically supported and evaluated by the FU.
The aim of the TK Depression Coach is to promote self-management skills in people with mild to moderate depression. The content is based on the classic cognitive-behavioral treatment concept, which can be optimally implemented using the possibilities of the Internet and new media. The coaching begins with a comprehensive online assessment that determines whether the program is fundamentally suitable. The information obtained in this way is validated through a telephone interview with a specially trained psychologist from the Free University of Berlin. If it becomes clear during the telephone conversation that the coaching is not suitable for the person concerned in their current life situation, advice will be given on site about alternative support offers. For everyone else, the coaching starts: Within about six weeks, the participants go through a structured task program, complete writing tasks and complete multimedia audio and video training. A central question in the pilot phase was: Is an individually supervised intervention by an appropriately trained psychologist “at the other end” more successful than pure human-machine communication? Both variants are available on the market. For this reason, the 1,000 or so participating TK insured people were randomized into two study arms. In the “automated” arm, individual feedback was only provided upon request; in the other study arm, participants received detailed written feedback on a weekly basis. Psychologists and participants communicated in encrypted form via a password-protected online portal on a specially secured server outside the TK. To ensure maximum data security, the mTAN procedure known from online banking was used. For the therapists, this meant that they had to request a TAN number before each login. This complex process has proven itself; Because many people found the offer interesting and wanted to take part, but had concerns about data security. This topic was one of the most common concerns that interested parties turned to the consultants with before the coaching began. After explaining the underlying data protection concept, almost all interested parties were willing to participate.
The evaluation results of the FU Berlin show impressively: the coaching works. There was a significant reduction in depressive symptoms in both groups. In the supervised version, however, the effect is significantly greater, the dropout rate is lower, and satisfaction and willingness to recommend others are higher. In addition to the quantitative evaluation, the numerous individual feedback from the insured, which was given at the end of the coaching via a free text field, was informative. The participants rated the offer very positively. They particularly appreciated the easy and uncomplicated access without having to make an appointment or wait. Many people are familiar with behavioral therapy exercises. Many people find the ability to do it online without paperwork, save it and view it again and again as practical and motivating. There was criticism of excessive standardization or a lack of individualization and flexibility of the program. As expected, this point of criticism was expressed more frequently in the automated version. Our conclusion: What has already been proven many times by research is also shown in our pilot project: online advice for depression works. The question remains: What does it have to be like so that people can use it? The results of the project suggest the following:
• Online programs must be user-friendly and intuitive to use. And (even if it's about a serious topic): they have to be fun.
• The user must be able to understand that his data is secure at all times and that the program is serious and well-founded, ie that it meets certain (yet to be defined) quality standards. The latter affects both the content and technical design as well as the qualifications of the consultants.
• The human factor is crucial. Programs with individual support are more effective than those based on pure human-machine communication.

The participants want a program that responds as flexibly as possible to their individual needs. Most online offers - including the TK-DepressionsCoach - currently only offer “one-fits-all solutions”, meaning there is a standardized program that works exactly the same for all participants. Future research should focus on flexible, modular and ideally learning systems that can provide each participant with a personalized program. The flexibility also means that, if necessary, it can be transferred to personal therapy on site. In the sense of a stepped care approach, online programs should therefore be part of an overall treatment offer that can be tailored to the individual needs of the user.
Conclusion and outlook
The examples shown show that it is not a question of “if”, but rather “how” digital care is designed. And about the “who”. TK will actively shape current and future developments and is expanding digital care offerings, including within the framework of the innovation fund. The TK is committed to finding out how the introduction of telemedical applications can be made easier and is developing proposals for the approval and evaluation of health apps. Our own business processes are also being continuously digitized, such as uploading AU certificates. And TK is already developing an electronic health record (eGA) for its insured persons. According to the SmartHealth study, a large majority of 91 percent associate the eGA with the hope of better collaboration between the treating doctors and therapists. In order for processes in the healthcare system to be made more efficient and transparent, all relevant players need to be digitally networked.

from:
Mandy Kettlitz,
Dr. Anne Moschner,
Dr. Thomas Ruprecht,
Dr. Thomas Nebling,
Dr. Beate Bestmann*