EHTO Trends in Health Telematics in the European Union


	Updated: Dec 6, 96
GERMANY

Health care in Germany is financed through health insurance. Care is delivered by two complementary sectors: general and specialist ambulatory care practitioners, and the hospital sector (with only a marginal outpatient sector). Hospitals are about one-third publicly owned (mainly the larger hospitals), one-third private, and one-third church or other charitable organisations. The federal states are responsible for the provision of health care, under the provision of federal regulations. Significant changes are now coming about as a result of new federal regulations, designed to contain the increasing costs of health care, and also permitting hospitals to enlarge the outpatient sector, in particular by ambulant surgical care.

Following changes in the federal social law telematics implementation in the health care sector is required at least for administrative data exchange between practitioners, hospitals and regional sick funds. A national strategy for the use of Information and Communications Technology (I&CT) in the public health insurance system has therefore become apparent to a small but growing extent.

In the area of general practice, which includes dentists, about 75% of practitioners currently use information systems, mainly for administrative purposes. Software developments conform to standards for diagnosis and drug coding, and patient records. The Federal Sick Funds Physicians' Association (KBV) offers accreditation for software products. The new regulations have included the introduction of a patient data card, which incudes basic patient administrative data. The KBV offers a patient administration system free which incorporates this data, and ICD-10 diagnosis codes have to be applied to all patients for the future.

Almost all hospitals have systems incorporating local networks, but these are mainly restricted to administrative systems. Many have been developed through collaboration between hospitals resulting in "public" software. Development of clinical systems is now being encouraged by the (insurance) requirement to show details of admission and diagnosis in every case.

Policy and Funding

Although IT health policy and research funding is the responsibility of the federal states (Bundeslander), there is a legal federal framework. The federal social law defines the basic elements of the health care system. In particular it regulates the health service structure covered by the public sick funds and defines the responsibilities and interactions between hospitals, general and specialist practitioners, their legal bodies and the sick funds. In this respect the federal government defines to small but growing extent the IT-strategy in health care. The federal government also funds research work in these areas.

Degree of Penetration

Use of Computers in Primary and Specialised Ambulatory Care
At the present time around 70-80% of general practitioners and office-based specialists (in former West Germany) use computers in their practices, mainly for reimbursement purposes.
Insurance Cards
Following a recent change in the law, all legally insured German citizens (more than 90% of the population) have been issued with a chipcard containing details of their Insurance cover. 100,000 medical and dental practices and 50,000 hospitals have been equipped with card readers and printers. At present, use of the card is restricted to administrative data, and storage of medical data is prohibited, though it seems likely that this situation will evolve over time.
By making available administrative information and details of insurance coverage in a standard format, the introduction of the chipcards will simplify accounting procedures whilst establishing a nation-wide information and communication network. It will also encourage doctors to use a computer system more generally within the practice
In the Koblenz region patient data cards have been introduced in primary health care on a voluntary basis. There was a high level of interest and acceptance on both the doctors and patients side.
Hospital Information Systems/Computers in Hospitals
Hospital information systems are widely used for management and - with the exception of certain departmental areas - to a lesser degree for medical purposes. Laboratory management systems are commonplace, and computerised systems are used also in radiology, radiotherapy, and cardiology. Stand alone computer systems are also frequently used in association with vital signs monitors in intensive care departments and operating theatres. The first broadly used systems were developed under the guidance of a joint federal/state initiative. With increasing pressure on hospitals to increase their efficiency more comprehensive systems originally developed and used in the industrial fields are now being introduced into the hospitals. Computers are also widely used for patient administration purposes including minimum basic data sets, discharge letters and operating theatre schedules.
All German pharmacists use computerised systems for automated billing, for their supply-control and communication with their suppliers. They contribute to a drug information system that allows a nation-wide pharmaceutical usage data collection and reporting system (published as a book or CD-ROM).

Key Initiatives

Many software programmes are available both for medical and a variety of management purposes including health insurance documentation, budgetary control, invoicing systems, health care contracting procedures and resource management. Use of a programme licensed by the Regional Sick Funds Physicians Association programme is a condition for reimbursement. At present about 55% of doctors in ambulatory care routinely send their reimbursement data on diskette to their Association but the intention is to replace this with an EDI (electronic data interchange) system.

The Federal Sick Funds Physicians Association has made some software available, including a drug information system on diskettes which is updated monthly. Doctors wishing to become affiliated members of their Regional Sick Funds Physicians Association are required to use standard administrative and medical data formats. These have therefore been incorporated by software manufacturers into their products. This facilitates the exchange of information and also makes it relatively easy for a doctor to change his system.
Computerised communication in the hospital domain is governed by new rules defined in the federal social law. From 1st of July 1996 electronic data transfer between hospitals and regional sick funds will be implemented. A data set for transmission based on EDIFACT standards has been developed. It includes ICD-10 for admission and discharge diagnosis and ICPM similar procedures for surgical interventions. In 1995 the electronic data transfer was tested and validated between selected tracer hospitals and regional sick funds. The implementation of EDI is also intended to support better care planning.

The Bavarian health network is another example of a regional initiative. The first projects started in late 1995 with teleconsultation with university sites; health information provided to doctors and citizens by a publishing company (Burda); and a third addresses health care integration.

Training

Curriculum contents have been developed and published, and generally speaking, education in health care informatics is fairly well established in clinical training schools, polytechnics and universities. Nursing curricula guidelines do not have an obligatory informatics component, though many nursing schools do offer it as an option. A special medical informatics curriculum is offered by the universities of Heidelberg/Heilbronn, Hildesheim and Lubeck. Almost all university medical faculties now have a chair in medical informatics, often combined with medical statistics. Possibilities also exist for postgraduate studies in medical informatics.

DATA PROTECTION

The protection of confidential data is the subject of a series of federal and state laws which have been developed over a period of more than twenty years. In addition to this basic framework, there are many more specific regulations contained in laws relating to hospitals and cancer registries, in civil, criminal and social legal codes and in codes of medical conduct and ethics. A certain number of problems are encountered in relation both to medical treatment and research as a result of these extremely stringent regulations.

NETWORK DEVELOPMENT

There are many local area networks within health institutions including hospitals, large GP practices, laboratory service and health insurance organisations, but with few on-line links between them. The new legal regulations mentioned above have established a trend towards increased network communication of both administrative and basic medical data. These exchanges already take place between hospitals and insurance companies. As cheaper hardware and software becomes available for medical applications greater use of networks for teleconsultation and multimedia is expected.

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