E-HEALTH: E-CLINIC LETTER PASSES THE PRACTICAL TEST
For a year, KV Telematik GmbH has been asking doctors to test its E-clinic letter. 26 networks have joined in, with over 120,000 electronic letters being sent. The system is up and running, say KVTG Managing Director Dr Florian Fuhrmann and Chairman of the Board of the Agentur deutscher Arztnetze, Dr Veit Wambach. Incentive systems for hospitals are still lacking.
By Rebekka Höhl
Ärzte Zeitung: The great field test ran for a year - from November 2015 to the end of 2016. 26 doctors' networks were involved. If you draw an initial interim evaluation: how happy are doctors with the E-clinic letter via KV-Connect?
Dr Veit Wambach:
In our Nuremberg doctors' network QuE, including after the test phase, 95 per cent of doctors are taking part in the E-clinic letter via KV-Connect. During the field test, we sent over 10,000 clinic letters electronically within the network. At my own practice, I am currently receiving six to ten E-clinic letters a day. These are of course - and this must be made clear - essentially in a better condition than if I receive them by fax. Many colorectal surgeons are still sending me colonoscopy images by fax, for example, so they arrive on my desk in black and white and are accordingly almost impossible to interpret. With E-clinic letters, I also get them faster and with a level of data protection that I don't get with a fax.
Dr Florian Fuhrmann
- Managing Director of KV Telematik GmbH (KVTG), a subsidiary of KBV, since 2014. KVTG develops telematics applications for the direct exchange of data in outpatient care and its interfaces with hospitals.
- He began his academic career at the University of Erlangen-Nuremberg. As a DAAD scholar, he completed his Masters degree in economics in the USA and gained his diploma in business management in Germany.
- Dr Fuhrmann has already been working in healthcare for more than 13 years, in particular in the fields of e-health, telematics, managed care, pharmacy and outpatient and inpatient care.
Dr Veit Wambach
- Chairman of the Board of the Agentur deutscher Arztnetze e.V. and the Nuremberg Quality and Efficiency Health Network (QuE) which networks 126 GPs and specialists.
- Deputy Federal Chairman of the NAV Virchow Group
- Registered as a specialist in general medicine in Nuremberg for 30 years
Dr Florian Fuhrmann: Data protection in particular is also the reason why we developed the KV-Connect channel with end-to-end encryption and made it available to doctors.
The test actually went particularly well in the QuE. This is partly due to the fact that the network is a highly professional one, one which a project can latch onto in many places. We also have other networks in which it worked very well. There are even networks in which the test wasn't the number one priority: in these cases, they thought they've give it a go too. In those situations, there were a few more problems. Another component is the sales and service partners: it varies from region to region how deeply involved the service partners are with the subject of the E-clinic letter. This then of course has an impact on the installation process. All in all, we sent over 120,000 E-clinic letters. In March alone, we sent 16,000 E-clinic letters, 30 per cent more than in the previous month. This more than a proof of concept.
So how long does it take, on average, to install KV-Connect?
Fuhrmann: It depends whether the service partner needs to come to the practice or whether remote maintenance is possible. It also varies from PMS (editor's note: practice management system) to PMS how long this process takes. However ultimately all of the modules are included in the PMS and they just have to be enabled, so it is not a big job.
Wambach: At my practice, the process actually took just ten minutes. My provider does not charge any additional fees for the installation and use of the KV-Connect module. This is unfortunately not the case for all PMS providers.
Fuhrmann: Around 85 per cent of the PMS market implemented and audited the E-clinic letter with us. The question over whether fees are levied or not varies considerably. As KV Telematik GmbH and even as KBV, we have no influence over this.
The E-clinic letter is also intended to drive cross-sector communication forward. How is it looking? Are hospitals already getting involved with the E-clinic letter?
Wambach: In the QuE we so far don't have any hospitals on board - even though we'd like to. Connecting the system to hospital information system (HIS), however, appears to be very difficult. With the MPS it's different, because these work with classical practice software.
Fuhrmann: This is an experience we also had at KVTG. So far, we have two HIS, which we audit. The doctors do want to communicate with the hospitals, however. Discharge management could give things a bit of a boost here: if the letter needs to be with the doctor on the day of discharge, what other option do I have than to send it electronically? Surface mail will not deliver it on the same day, and faxing isn't really secure.
I was personally disappointed that the demand for the discharge letter, which we still had in the draft bill of the E-Health legislation, was ultimately deleted. Hospitals were to receive one Euro for transmitting the letter on the same day and the board-certified doctor 50 cents as the recipient. I am certain that these projects work best through multipliers. This is why we turned to the agency of Agentur deutscher Arztnetze (German doctors' networks agency). - After all, the multipliers already using networked care are usually doctors' networks and hospitals. However as the hospitals have moved away from this "business model", many HIS providers have also turned to us.
Let's come back to the key word of funding: what do you think of the flat-rate sum of 55 cents per E-clinic letter that the sender and recipient have to share, as it were? From a doctor's perspective, but also from the perspective of the KVTG? Does the incentive help, or is it more of a hindrance for the E-clinic letter?
Wambach: Bavaria's health insurance fund has already put a lot of money into the KV SafeNet. So I would say that, here in Bavaria at least, the funding has been exemplary. With the additional funding from the EBM now, surely everyone will be able to find a way forward once they realise what advantages the E-clinic letter actually brings. My personal opinion is that the benefits are so great that the additional funding will actually lead to as many people as possible introducing the E-clinic letter as quickly as they can. The great advantage of individual service remuneration is also that things that are not faring so well can gain ground. The problem at this point is that the legacy incentive systems counteract the current objectives slightly.
Fuhrmann: We are only providers, after all. However I do not find it too fortunate that the 55 cents you're giving as the incentive is the same as the sum you receive for a fax, which is what we're trying to do away with, after all. The fact that both parties - the sender and the recipient - get something out of it was certainly a practical idea, since both had to have a certain technology with VPN access and KV-Connect. However doctors often tell us that, if I send a fax, I get 55 cents. If I send an E-clinic letter, I get 28 cents.
So once again, it would be useful to include the discharge letter in the incentive. This would help the E-clinic letter and the electronic ID cards for health workers (eHBA) to become widespread more quickly.
Wambach: This would have been ideal, especially in relation to what incentives there are for hospitals to come into direct contact with board-approved doctors.
You have worked a lot with software companies to bring the E-clinic letter via KV-Connect to the wider market. Now we're hearing all the time that it's so difficult to communicate across system barriers. Is this true?
Fuhrmann: With regard to KV-Connect and the clinic letter, I can say that the software industry has worked with us very closely, like partners.
We did ultimately use the vhitg standard as the basis for our clinic letters, which comes from the software industry. We developed this and found common ground with associations and the industry. The fact that 85 per cent of the market has implemented our E-clinic letter without being obliged to shows that it has worked very well. We also held an interoperability workshop with the providers where we literally sent letters back and forth until it could be sent and received by every system.
The political discussions around a lack of interoperability are also based around module interfaces and the costs of these; it's less about the secure communication channel. And this is where politics needs to lead the way. We cannot expect individual software companies to open interfaces and then others not to do so. The pitch must be level for everyone.
What's the situation with batch signatures: do they really work, and how many e-letters can be signed at once?
Wambach: I'm certainly very happy if it works at all. I've got my card and my reader outside, and I can sign. That's it.
Fuhrmann: We designed the field test with doctors' networks before the E-Health legislation came into force. The signature rule for funding from January 2017 came in just before the law was passed. For a successful KVTG audit, we always insist on the electronic signature in the software system. In the field test, the signature was not mandatory for the participants, however. We did not want to put this additional hurdle for doctors in place in the test. The doctors' organisations are still obliged to roll out the eHBA.
Wambach: Acceptance among colleagues of the electronic doctor's ID is certainly not at a level that the organisations would have liked.
And what's the situation with the acceptance of the E-clinic letter among networked doctors? Even beyond the field test?
Wambach: The E-clinic letter was very well received in the networks. However from the AdA too, we received feedback that some doctors saw the fact that there are PMS providers who are charging a relatively large amount of money for the application as a negative aspect. Without this hindering market policy, the E-clinic letter would certainly be more widely used in everyday practice settings.
And if it were possible to give a score for satisfaction?
Wambach: The networks also represent many opinions. So there's no single score, but rather the Gaussian distribution curve - and with us it's pushed relatively far towards the better scores. Overall, it is an important step for us. The agency of German doctors' networks believes the KV system to be a system worth supporting and maintaining. Especially also in relation to the question of how the KV system can survive in the future, the E-clinic letter and KV SafeNet are important elements in an increasingly complex market for safeguarding the comprehensive care of people and offering doctors technical opportunities to progress in the domain of digitalisation.
The BMG has recently announced its clear support for KV-Connect. The communication channel for the telematics infrastructure (TI) is set to be certified before the year is out. This involves an - as yet unconfirmed - but clear promise of funding for the E-clinic letter. How will KV-Connect establish itself in the future as the standard for the E-clinic letter? And is this an opportunity to improve the funding situation?
Fuhrmann: The pledge by the BMW that KV-Connect will also be used in the TI is a pleasing affirmation of the work by the software industry and the KV system. It is not only affirmation of the success, but also and in particular of the way in which we collaborated.
However this statement is not a complete surprise. The end of the product lifecycle of the fax for sending patient data came no later than the introduction of Voice over IP. KV-Connect is established nationwide on the market and in all PMS. When TI becomes widespread, the support for KV-Connect in the TI by the legislator will be an important argument for doctors who previously lacked the medical applications as well as insured party master data management. Corresponding remuneration for the E-clinic letter should therefore be in the interests of the health insurance companies and the doctors.
KV-Connect is already the manufacturer-neutral communication standard for the encrypted exchange of medical and organisational data directly from the PMS. This standardisation requires a lot of commitment from the software companies, for which I would like to express my thanks at this point. Thanks also to the agency of German doctors' networks, the networks and of course to the many doctors who took a constructive and open approach to the field test and therefore smoothed the way for the E-clinic letter via KV-Connect to enter standard care.
What are the next applications that doctors can expect via KV-Connect?
Fuhrmann: We already have a series of applications: the documentation systems such as eDMP or eDialyse, the billing with the health insurance providers, etc.
The big topic this year will be the transfer of laboratory data. The LDT 2.0 laboratory interface is already over 20 years old. Where LDT 3.0 is coming in and digital patterns are approved, requests and the return of results electronically are also possible. The changeover phase to LDT 3.0 will expire at the end of this year, so the software market will be adjusting to this accordingly over the next two quarters. Laboratory data communication will make KV-Connect even more interesting for many doctors.
