From Agreement to Realization: Six Years of Investment in Integrated eCare in Kinzigtal

Introduction

A key problem of the German health service system is its institutional fragmentation, as in many other health systems: public health services, primary and secondary ambulatory care (outpatient care), and hospital (inpatient) care are organized and financed largely independently from each other. The separation between office-based (ambulatory) and hospital-based (inpatient) physicians is stricter than in other countries. This historical division of health services is connected to a reimbursement system without incentives for outcome-oriented health care or prevention so that quality- and value-based incentives have been virtually non-existent (Schlette, et al., 2009). Doctors in ambulant practices receive a kind of fee-for-service reimbursement. There are strong incentives for (technical) interventions. A cap which varies by the physician’s medical specialty restricts the total amount of all such payments. The fee schedule is based on services actually provided and the payment caps are comparable to a salary with the intention that incentives for an (unnecessary) extension of services are being avoided (Busse and Riesberg, 2004).

The shortcomings of such a fragmentation into health care sectors have often been noticed (Amelung et al., 2012). Most prominent are the problems around insufficient communication between the different health professionals that work on the same patient. First it leads many providers to perform redundant services and, therefore, to unnecessary expenditures for ambulatory care, resources that are lacking for required care in other fields. For the patients concerned, these redundant services imply not only a waste of time but also – at least in situations such as X-ray – unnecessary risks (Schonfeld et al., 2011). Second, insufficient communication may cause harm directly because health professionals may give false advises and false or incorrect medication because of lack of information. Up to 5% of all hospital cases are estimated to be the result of wrong, too high or too low doses or of incompatible medications and around 25,000 deaths are calculated per year by the same reasons (Schrappe, 2005). Better and quicker communication delivered to each participant in the care process could help reducing this burden significantly (Hammersley et al., 2006).

The idea of implementing mutually compatible electronic means of communication and semi-automatically data processing for cooperating providers of different sectors of care has remained an utopia for German normal care up to now, with 68% of primary care physicians working in solo practice and another 31% in small group practice (Schlette et al., 2009) and more than 150 different IT-systems used in these practices. The same holds true for the idea of creating a system of electronic patient records accessible to all providers treating a given patient (patients’ informed consent provided). By facilitating the cooperation of all health care professionals, e.g. by jointly developed integrated care pathways, synchronizing medications and by developing electronic patient records across the sectors of care Gesundes Kinzigtal aims to create the preconditions for a better-coordinated follow-up. This chapter will report on the experiences gained during the development and implementation of eCare into the integrated care model of health services in Gesundes Kinzigtal.