Opinion piece on the telematics infrastructure: “The measure is full”.
19 years after the foundation stone was laid for the telematics infrastructure (TI) in the medical sector, the question arises as to whether the health network, which was introduced with a lot of money, has brought the desired added value. The mood among the users, the doctors, is in the basement. Rightly so? Yes! Are these minor errors in the system that can be fixed, or are they fundamental structural or system errors that require a reset? There is much to suggest the latter. In my view there are four cardinal errors:
Michael Evelt has been deputy chairman of the Westphalia-Lippe Association of Statutory Health Insurance Dentists since 2017.
1. Lack of awareness among politicians when dealing with the medical profession
Every error in the telematics infrastructure, no matter how small, is currently leading to the entire structure of TI being questioned in the media, primarily on social networks. This is where all the TI frustration comes out, because since the introduction of the telematics infrastructure, the legislature has concentrated on forcing the number of users and thus the accelerated implementation of the TI introduction through an excessive deadline and sanctions policy. This meant that the first cardinal mistake was made at the beginning of the telematics infrastructure.
Doctors chose the medical profession in order to heal patients as freelancers. This also means that they want to decide for themselves and freely in their own practice. Patient care is the focus. The technology used is only a means to an end. However, the legislature has imposed penalties on the TI and its components in the form of fee deductions.
It is obvious that politicians and Gematik have not managed to convince the medical profession of the telematics infrastructure and the use of TI applications. She doesn’t pick up the medical profession. On the contrary: Gematik is increasingly losing doctors. Frustration and TI dissatisfaction are the result of years of misjudging the situation.
At the same time, the lack of acceptance of TI by politicians is justified by the blockade attitude of the medical profession. As a result, doctors are assumed that use is only possible par order du mufti through sanctioning and setting introduction periods. This is not the case, because the medical profession is open and positive about digitalization. However, the accelerated introduction of digitalization, such as the introduction of the telematics infrastructure, must not become a political end in itself.
2. Ever shorter deadlines coupled with sanctions
Digitalization is good when it supports the processes in the doctor’s office or, better yet, when it improves patient care. This is where the second mistake lies: Sitting in the ivory tower, new applications are being introduced into the supply chain through legal regulations in ever shorter periods of time with penalties that are subject to sanctions. As recently announced by the Digital Act, in which e-prescriptions will be mandatory on January 1, 2024. If the service is not used, two sanctions will be imposed: a fee deduction of 1 percent and an additional 50 percent reduction in the TI flat rate.
The only application that can be used profitably and beneficially in care since the introduction of TI is an application by the dentists themselves. This is the introduction of the electronic application and approval process for dentists. This means that dental services can be applied for electronically from statutory health insurance companies via the TI. The accelerated approval also means that patients can receive care in a timely manner. The acceptance of this application is enormous because the doctor can see a benefit in terms of care.
Instead of putting speed in the foreground when introducing it, politics and gematik should finally put usability in the foreground. Sanctions and deadlines are then completely unnecessary and have never been a suitable means of achieving user acceptance. On the contrary, they lead to growing frustration. No profession wants to be bullied.
The most recent example of the frustration of the medical profession is the connector failure of a well-known manufacturer. Of course something like that can happen. Everyone knows that digitalization or the introduction of new products does not go smoothly, but this incident joins the series of bankruptcies, bad luck and mishaps. This is the limit. The medical profession is fed up with applications that do not add any added value to care or with components that run unstable. Which private household affords a washing machine that has to be restarted five times to get the laundry clean? No consumer does that. Such devices would disappear from the market.
Technical errors that disrupt or bring to a standstill the processes in practices and the lack of added value of the applications are already problematic. If fees are then threatened and TI services are only available through additional payment from doctors, it is clear that no one wants the system.
3. Intervention in the free market economy by the state
The principle of the free market economy was violated for the TI – with fatal consequences. Here lies the third cardinal error. Demand and supply are usually responsible for determining the price of products. However, the state controlled demand behavior through sovereign intervention in the market. Doctors have no choice if they want to avoid fee deductions. In this respect, demand is fixed and does not have to develop. This creates an incredible advantage on the provider side. Because they do not need to stimulate demand behavior by varying pricing. As a result, the providers can determine the price themselves and are apparently based on the maximum rates of the specified reimbursement amounts from the TI refinancing. This results in financing gaps that the practices have to bear.
4. Lack of regulation regarding the approval of market participants
The fourth cardinal error becomes clear in the exchange of connectors. Why do the connectors need to be replaced? According to the BSI’s specifications, even the current RSA certificates can still be used until December 31, 2024. This time would have been sufficient to develop alternative solutions for replacing connectors. At least this has now happened with the remote certificate exchange. Other solutions such as the TI Gateway solutions are in the approval process.
The questions that have so far remained unanswered are: Why could a provider ignore the normative requirements of Gematik without consequences (conventional penalties or measures restricting approval such as temporary withdrawal of approval)? Why was it not possible to develop the existing certificate renewal solutions and TI gateway solutions so quickly within five years that a hardware replacement of the connectors would have been unnecessary? Instead, the costly hardware replacement was ordered. This gives the impression that the industry is making the specifications in disregard of the specified standards. In other areas of life this is unthinkable and clearly regulated. A car is declared roadworthy or shut down by the TÜV.
Politics must take doctors seriously
In the TI system, clear regulations from the Gematik approval office are missing or are not applied. This means that providers can act freely in their own interest. This decision cost the umbrella association of health insurance companies and thus the insured a lot of money that could have been used more sensibly elsewhere in the health care of the insured.
The TI system cannot work like this. Politicians are advised to take the mood among doctors seriously and not always dismiss it as moaning at a high level. Ultimately, it is the doctors in Germany who ensure people’s health care and not the legislators in Berlin.
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