In­ter­change in times of crisis

Anyone who wants to understand the digitization of the German healthcare system and the connection with the current crisis must first take a step back in time: In 2004, the Act for modernising the statutory health-insurance system (GMG) came into force – triggered by the Lipobay affair* three years earlier, which showed the need for electronic medication control authorities. The electronic health card (eGK) is one result of this development we have all known and held in our hands since 2011. However, the introduction of the so-called telematics infrastructure (TI)* provided for in this law is still dragging on today. Since January of this year, the Digital Healthcare Act (DVG)* has been in force, which is intended to enable the broad use of digital services and also the much-discussed electronic healthcare report. A lot has already happened in the area of telemedicine and eHealth – and yet there is still a lot to do, Swoboda emphasizes. The electronic health card does not yet fulfill its actual purpose; a broader introduction of tools such as video consultation hours often fails due to the cost issue. Comprehensive networking of all health players is no longer just a pipe dream, but has not yet been implemented either.

German health care system lacks comprehensive inter-institutional networking

"Basically, our entire health care system suffers from the fact that we now have reasonably valid information systems within the individual institutions themselves. But what we lack completely in Germany is inter-institutional networking," Swoboda states. In other words, there is a shortage of bundled access to information about patient flows, previous illnesses, and recovery processes – and above all, there is no overview of the big picture: "This means that we have many, many individual cases, but not one big case," the physician complains. Bureaucratic and formal hurdles are also proving to be counterproductive: For example, doctors but not nurses have access to the digital patient file – without a general nursing council, they lack the necessary health professional card. In view of the important role of nurses, this is an untenable situation, Swoboda emphasizes.

According to Swoboda's assessment, COVID19 has now significantly exacerbated the imbalance due to the posdtponed digitization processes within the German healthcare system. One example that has been widely discussed in recent weeks is the unclearly quantified capacity of intensive care beds in Germany, but the lack of an overall view of when, where and how which patients have been tested for the virus is also problematic. If such elementary figures are unclear, valid treatment planning is hardly possible. If, on the other hand, clinics, hospitals, nursing homes and doctors' practices have joint access to a reliable and complete superordinate data situation, treatment processes can be coordinated more efficiently. This overview can sometimes be (life) decisive.

Concerted data access can help acutely and preventively in pandemics

Such intelligent networking pays off in acute emergencies – can it also serve as a kind of early warning system? Epi- and pandemics, such as the one we are currently experiencing, can hardly be predicted, Swoboda points out. But there are indicators that, if recorded in time, can indicate certain developments. In the case of COVID19, for example, the indicator of elevated temperature plays an important role; individual warning systems had also classified this factor as an alarm signal. If such data are now collected more systematically in general screenings, they can provide earlier information about imminent waves of infection.

"There have always been major epidemics, some of which have decimated humanity considerably. These are normal risks that humans have – but that doesn't mean that you can't and shouldn't do something about them with modern methods," says Swoboda.

Why do also these modern methods need their time and why must one count on a longer time span, in order to bring COVID19 under control? One reason is the process of vaccine development: viruses circulate both in their natural form, the so-called wild type, and in mutated forms. In the laboratory, a distinction must now be made between such wild type strains and mutated COVID19 strains. This separation is extremely time-consuming, explains Swoboda: "Under these circumstances, I cannot imagine that the vaccine will be available this year. Contagious viruses or bacteria are usually not particularly deadly – they must preserve their transmission paths. With increasing population density, however, the relationship between infectivity and lethality shifts more towards lethality, explains Swoboda. Ultimately, there must be better early warning systems here.

Thus, the health care system benefits from inter-institutional data networking not only in ad hoc treatment, but also in prevention. "Of course, this is an enormous amount of data that needs to be scanned regularly – this is where AI comes in," adds the research professor, who is himself not only a licensed physician but also a computer scientist.

The delayed introduction is less due to specific actors such as gematik GmbH* - it is mainly fundamental concerns that make a concerted implementation difficult. Could the corona crisis now possibly provide the necessary impetus to advance the digitization of the healthcare system more constructively? It must, says Swoboda: "These are structural innovations that are long overdue. It's time to make a proper job of it in times of the current crisis.“ He is confident that ethical issues that have been discussed for a long time will now come back to the fore. 

The following maxim applies to basic data protection and ethical questions: The patients have the final say

Data protection, for example in the digital patient file, has repeatedly proven to be the linchpin of the debate. One critical point is that patients are currently unable to decide for themselves which data should be deleted from their own files. "In the end, however, the advantages outweigh the disadvantages," says Swoboda, who has been working with medical IT systems for years. What is often overlooked in this context: If access to patient data is not organized interinstitutionally and legally, the industry steps in. The blood pressure values of diabetics, for example, which are documented via a smartphone app, are ultimately the responsibility of the manufacturer - family doctors only have indirect access to them through their patients and must base their treatment on measurement data that they have not collected themselves. Swoboda sees the privatization of data, the use of which is not always clearly communicated by the industry ("How far does this go? Does the insulin pump at some point learn to secrete happiness hormones?"), a development of which one must be aware and which must be prevented – and, according to Swoboda, this can only be achieved through the introduction of electronic patient files.

The question of last will and self-determination is also currently becoming more important. What happens, for example, if a person suffering from COVID19 refuses vital ventilation? At the moment, there is a lack of appropriate instruments to ensure the own will in acute cases.

All these ethical dilemmas can ultimately be based on one maxim, according to Swoboda: "It is difficult - and yet quite simple: the patient must always have the final say".