Fifteen years after the first legislative foundations were laid for establishing a telematics infrastructure in Germany, the record is sobering: To date over two billion euros have gone into networking the German healthcare system. Even the German Federal Court of Auditors criticized the project’s slow progress and unclear technical and legal standards in its latest report to the federal government’s budget committee. Policymakers have now recognized this as well and are working feverishly to engineer actions. These include some very welcome proposals, such as mandating that health insurers offer their members an electronic patient record by 2021. At the same time, however, there is some reluctance to tackle the far-reaching reforms that are needed. Securing a majority in the Organization for Telematic Applications of the Health Card (gematik) for the Federal Ministry of Health (BMG) is not a solution to the underlying problem. The standardization and certification processes should instead be organizationally separate from each other.
Driving forces in networking
The insured have scarcely seen any benefits so far. Those interesting medical applications have yet to materialize, and the electronic health card still isn’t “smart.”
At the same time, the digital world around us has been evolving at breathtaking speed over the last 15 years. Today it’s a given that most people use smartphones and tablets. Many actors in the healthcare sector — including the AOK — have responded to this in the meantime. We gave the topic of networking in healthcare momentum with the introduction of our Digital Health Network initiative. The Digital Health Network is a platform for the exchange of health information between patients, private-practice physicians, hospitals, and other actors within the healthcare system. It also includes a digital patient record for AOK members.
First pilot projects launched
The Digital Health Network has already been launched in two regional pilot projects in Berlin and Mecklenburg-Vorpommern, and the first group of AOK members is already seeing concrete benefits from the new networking system: They can access the health information provided by their physicians at any time via a portal and make it available to other physicians. They have control over their data and can decide for themselves which doctors will be able to access which information. In Mecklenburg-Vorpommern, two AMEOS hospitals and HaffNet, the regional physician network, are involved in the project. They provide care to some 7200 patients insured by the AOK. The main focus within the participating hospitals is on admission and discharge management and document exchange between the hospitals and private-practice physicians.
In Berlin, we are working with Sana Kliniken AG, Germany’s third-largest private hospital group, and with Vivantes, the largest community hospital group. The first step was to link seven obstetrics departments to the network, with more hospitals and healthcare centers to follow. Each year they provide care to a total of 114,000 AOK members who can benefit from networking. This pilot project focuses on communication between the hospitals and expectant mothers. For example, they can make their pregnancy records, reports from previous deliveries, and results from outpatient checkups available. The clinicians in turn can upload structured documents like ultrasound, laboratory, and surgical reports or discharge letters to the record. This solution undergoes continuous refinement based on feedback from real-world users.
We are certain that the network will have a positive impact the care for our members.
Four companies, one platform
All of the experience we gained from these two pilot projects with our partner facilities will be incorporated into development of our nationwide health network. Once the software licenses for the project were granted, we contracted with a consortium of three experienced IT companies in January 2019 to supply the individual components of the network. The contract was awarded to x-tention Informationstechnologie GmbH, a one-stop IT solution provider, along with the two leading software manufacturers for IHE systems, InterComponentWare AG (ICW) and soffico GmbH. In the coming months, these three companies will develop a platform for nationwide data exchange based on the Orchestra eHealth Suite software. Atos Information Technology GmbH is also on board as a partner, complementing the trio with digital certificate solutions for secure communication between all the parties involved in the health network.
Ready for launch by 2020
We feel that awarding this contract to develop both the central and decentralized components for the health network is an important step in moving the project forward. One of the main issues is developing the platform for nationwide data exchange between the parties involved. The IT contractors will also be developing the most important applications for the Digital Health Network, ranging from electronic discharge letters to medication charts to electronic medical alert cards and immunization records. Other components will allow users to submit supporting documents like certificates of incapacity for work, or to pull up status information, for example regarding copay exemptions for an insured patient. The project also involves laying the groundwork to connect decentralized hospital server structures, physicians, and existing networking projects. As of 2020, all AOK members, physicians, hospitals, and other actors will be able to utilize the network and digital record throughout the country.
Our goal with the Digital Health Network is to connect all service providers across sectors and thus place the focus on the exchange of relevant information. To do this we will link private-practice physicians and hospitals directly via interfaces so as to avoid added costs in time and labor, such as duplication of records and sending data manually. The participating physicians will decide which information to make available for exchange. Even now, during the pilot phase of network development, we are working closely with private-practice physicians and hospitals in order to incorporate their perspectives into the project and make it as simple as possible for them to use.
Security for sensitive patient data is one of the most important principles of the Digital Health Network. It provides that security in part through largely decentralized storage for medical information, which means that data stays where it is generated — in the hospital’s computing center, or on a server belonging to a private-practice physician participating in the project. Just a single link will be created in the health network, which other doctors can use to access reports and documents, such as x-ray images or discharge letters — provided that the patient consents to the exchange of data. Two-factor authentication also affords extra security when patients access their own digital records.
Technology built around the IHE standard
Unlike for-profit enterprises, the AOK has no interest in collecting patient data for commercial exploitation. Although it does offer its members the platform to exchange their medical information, the AOK itself does not have access to the data and documents supplied by the participating physicians. In developing our health network, we believe that simple integration and interoperability are particularly important. Therefore, the network technology is based on the IHE (Integrating the Healthcare Enterprise) methodology. This standard forms the foundation for cross-sector exchange of medical information, as well as for linking the Digital Health Network to gematik’s central telematics infrastructure.
Improving care for our members
But why is the AOK committed to networking in the first place? The answer is simple: Because we believe that it will have a positive effect on our members’ medical care. Greater availability of medical information will benefit not only the patients, but also the doctors treating them — across sectors and medical disciplines. Unnecessary duplication of tests and interface problems during hospital discharge will be avoided. Drug therapy safety will be improved with digital medication charts. And in an emergency, patients can get faster and more focused treatment based on their stored information. This is especially true for members with chronic illnesses who have multiple providers treating them and numerous physician contacts. Those doctors will be able to access all the relevant information through the Digital Health Network — subject to the patient’s consent. Our technology then enables the treating physician to choose the data and documents relevant to an individual patient’s diagnosis and treatment from the information available in their record. The physician only needs to look at the material that affects them and their patient’s treatment. That way, the sum total of all the information in the record can become a diabetic’s file from the diabetologist’s perspective, or a cardiological file from the cardiologist’s.
Data portability when changing insurers
We plan to make the network available to all actors in stages as an open platform. It will be our contribution to better networking in the German healthcare system — but we do not want to create any new barriers. Therefore, we are coordinating with policymakers and our competitors in this area. Because one thing is clear: The stated political intent calls for electronic patient records to be available to members of all statutory health insurance plans starting in 2021, and those records must have uniform technical standards. They should be developed in a competitive environment but based on uniform specifications. For example, members must be able to take their data with them even if they change insurers. This is the only way to achieve meaningful networking of all the actors involved. Because there are already more than enough siloed digital solutions that cannot communicate with each other.