Telemedicine and digital innovation: future prospects for the care of the chronically ill
Digitalization is revolutionizing healthcare for the chronically ill: from telemonitoring and wearables to artificial intelligence - new technologies are improving patient care. SEMDATEX spoke to Dr. Thomas M. Helms, an experienced cardiologist, honorary chairman of the German Foundation for the Chronically Ill and advisor to the German government on telemedicine issues, and Dr. Bianca Steiner, medical informatics specialist and deputy head of innovations in healthcare at the foundation, about the opportunities, challenges and specific potential applications.
Photos: © German Foundation for the Chronically Ill, Dr. Bianca Steiner, Dr. Thomas M. Helms
About
Dr. Bianca Steiner
Dr. Bianca Steiner is a medical informatics specialist and has been Deputy Head of Innovations in Healthcare at the German Foundation for the Chronically Ill (DScK) since September 2023. Dr. Steiner is involved in various national and international projects on digital innovations in healthcare. In addition, she leads the nationwide quality assurance measure DOQUVIDE: Documentation of quality in the collection of vital parameters by implanted devices. A particular focus of her work is the patient-centered development and evaluation of assistive health technologies for chronically ill people as well as the research and implementation of measures to increase adherence and motivation in digitally supported care processes, such as telemedicine.
Dr. Thomas M. Helms
Dr. Thomas M. Helms is an experienced specialist in internal medicine and cardiology. Dr. Helms is honorary chairman of the board of the German Foundation for the Chronically Ill (DScK). He is Director of the Peri Cor Cardiology Working Group / Ass. UCSF, which specializes in interventional cardiology and clinically invasive electrophysiology. As Cluster Spokesman of the eCardiology Committee for the "Society and Politics" section of the German Society of Cardiology, Cardiovascular Research (DGK), he is intensively involved in the further development of digital and telemedical concepts. In addition, Dr. Helms is a medical scientific advisor to the German government, various self-governing bodies and the German Medical Association on issues relating to telemedicine and the care of people with chronic diseases. His particular focus is on demonstrating the benefits and sustainable integration of innovative care concepts in the healthcare system.
SEMDATEX: Dr. Helms, as chairman of the German Foundation for the Chronically Ill and an expert in eCardiology, you are intensively involved with digitalization in healthcare. What role do you think telemedicine currently plays in the treatment of chronically ill patients?
Dr. Helms: In principle, telemedicine enables both diagnostic and therapeutic measures to be carried out across distances in terms of time and/or space, thus improving the prevention, diagnosis and treatment of chronic illnesses. Among other things, the use of telemedical applications can improve access to diagnostic and therapeutic measures. Particularly in rural or underserved areas (low physician density), telemedicine can make an important contribution to the continuous care of chronically ill people. In addition, resources such as travel time and travel costs can be saved. This is not only relevant in rural areas, but also for people with limited mobility. On the part of the treating physicians, resources can be saved or used more efficiently. The use of telemedicine not only reduces the number of (unnecessary) visits to the doctor, but also allows more time to be invested in patients with more complex treatment needs. For example, in the case of patients with cardiovascular diseases, key health parameters such as heart rate, blood pressure and weight can be measured at home and forwarded to the treating physician or a telemedical center for evaluation. This way, deteriorations in health status, including decompensation, can be detected early and appropriate measures, such as an adjustment of medication, can be initiated in time. As a result, hospital admissions can be avoided. Even simple telemedical applications such as video consultations, in which no health parameters are transmitted, can contribute to greater flexibility and efficiency. They facilitate the exchange between patients and practitioners, reduce the time required for check-ups and shift routine tasks. In addition, patients are more closely involved in their own care process. This also promotes patients' personal responsibility in dealing with their illness.
You are a member of various committees and working groups dealing with the digital transformation in healthcare. In your opinion, what specific progress has been made in the field of digitalization in cardiology in recent years, and where do you still see the biggest challenges?
Significant progress has been made in the area of telecardiology, among others. One milestone is the decision of the GB-A on telemedicine for heart failure, which came into force in December 2020 and not only enables data-supported management of patients with heart failure but also includes this service in the uniform evaluation standard as a new fee schedule item. Structured telemedical care supplements the outpatient services offered by the health insurance funds in order to enable seamless telemedical care for patients with advanced heart failure. The basis of the treatment concept is the cooperation between telemedical centers and general practitioners.
What role does quality assurance play in structured telemedical care, and what measures do you consider necessary here?
Despite existing quality assurance agreements (QS-V TmHi), which regulate the professional and technical requirements for the implementation and billing of services, there is a lack of suitable further quality assurance measures. Certification concepts for telemedicine centers, such as the DGK certification concept, should also be discussed further. The joint billing recommendation of the German Medical Association (BÄK) and the PKV Association for telemonitoring in chronic heart failure is also essential for telecardiology. The recommendation, which will initially be valid from January 2024 to the end of 2026, significantly improves the private health insurance reimbursement for telemonitoring in heart failure and includes external devices in addition to cardiac aggregates. The private health insurance policy thus enables telemonitoring to be carried out cost-effectively. The private health insurance policy also takes into account the latest evidence on the effectiveness of telemonitoring across the entire LVEF spectrum. However, there is also a need for improvement here with regard to the inclusion criteria considered so far (NYHA II-III, EF <40%; EF >40% with at least one hospitalization due to cardiac decompensation in the 12 months prior to the start of telemonitoring), in order to be able to include as many patients as possible. Furthermore, there is a significant need for training for medical and non-medical personnel in order to implement comprehensive telemonitoring in practice in the long term.
How do you think new technologies such as wearables, health apps and AI can further advance cardiology, and where do you see the biggest challenges?
These developments are undoubtedly driving digitalization in cardiology. Among other things, the acceptance of wearables and other mobile health applications (mHealth) is increasing as a supplement to traditional health care. For example, smartwatches can be used to record vital parameters or a simple single-channel ECG to detect signs of cardiac arrhythmias such as atrial fibrillation. In addition, health apps are increasingly being developed to support patients in dealing with their disease and strengthen their self-management skills. These are often not only about education, e.g. in the form of e-learning, and the monitoring of health parameters, but also about algorithm-based recommendations for action and therapy decisions. The recognition of such applications as digital health applications (DiGA) makes it possible to prescribe them as an “app on prescription”.
What are the hurdles for mobile health applications to be included in the DiGA directory? What measures can be taken to improve the market for digital health applications?
However, classification as a DiGA is subject to strict requirements regarding the medical purpose of the app and the risk classification as a medical device. In addition, there are immense requirements for data protection, the provision of evidence and certification as a medical device, which make it difficult for manufacturers to have their apps included in the DiGA directory. As a result, only a few applications can be found in the DiGA directory so far, and these have only been provisionally included in the DiGA directory and can therefore be reimbursed by the statutory health insurance funds. Another challenge in the use of mobile apps is the flooding of the market by a multitude of apps in the app stores and insufficient quality control. Many of the available apps have not been quality-tested. Approaches such as the CHARISMAH* study are attempting to solve this problem.
What potential do you see for using AI to improve the diagnosis and treatment of cardiovascular diseases, and what challenges need to be overcome to ensure these technologies are used across the board?
Developments in the field of AI also contribute to improving the care of people with cardiovascular diseases. For example, AI can be used to calculate the pre-test probability in patients with suspected coronary heart disease in order to achieve better risk stratification of dangerous narrowing of the coronary arteries. However, AI can not only support the risk assessment of cardiovascular diseases, but also diagnostics and therapy. For example, AI can facilitate the analysis of 12-channel ECGs or make personalized therapy decisions by weighing different device therapies against each other. Chatbots, which are used to educate patients and support self-management, are also becoming increasingly popular. This can help to reduce anxiety, promote behavioral change and reduce the number of doctor visits. However, challenges to the use of AI in cardiology include the traceability and transparency of decisions, liability and licensing issues, and compatibility with social and professional norms. In addition, AI applications can negatively impact the doctor-patient relationship. There is still a need for action in the areas of interoperability, data protection and widespread use.
Let's take an example: the DOQUVIDE project* aims to improve the documentation and quality of care for the chronically ill. Can you tell us more about the project and how it contributes in practice to optimizing healthcare for patients with pacemakers? What hurdles have you encountered in implementing it?
DOQUVIDE is a measuring instrument for recording the care reality of outpatients with implanted pacemakers / ICD / CRT-P / CRT-D devices and event recorders who receive telemedical cardiological care. In addition to cardiac events and vital parameters, which are obtained telemedically from patients with telecardiological devices, DOQUVIDE records the diagnostic and therapeutic procedure after reporting an event. For this purpose, four standardized forms, developed in-house, are used. Which event form is to be completed by the monitoring physician or qualified employee in the electronic documentation system depends essentially on the underlying cardiac event: (1) pathological atrial fibrillation, (2) device therapy – ATP or shock, (3) bradycardia, tachycardia or new atrial fibrillation, (4) ventricular high-frequency episodes. After a cardiac event is reported by a device, the electronic documentation system automatically generates the corresponding event sheet and stores a corresponding task in the system. The practices/clinics participating in DOQUVIDE receive quarterly and annual reports to check the documentation quality. DOQUVIDE makes a significant contribution to improving telecardiology in Germany. By analyzing the reality of telecardiological care in detail, the quality assurance measure contributes to the further development and independent evaluation of the effectiveness and efficiency of outpatient cardiac telemonitoring (quality assurance). At the political level, the results support the development of a uniform quality standard, promote the transparency of care and show efficiency potential. DOQUVIDE also offers a billable alternative to “telemonitoring for heart failure”. For example, DOQUVIDE can include all patients with various cardiovascular diseases, such as sick sinus syndrome or atrioventricular block in varying degrees of severity, who previously could not be included in structured telemonitoring for heart failure. One challenge with DOQUVIDE is data collection. The evaluations are based solely on the input of the monitoring physicians. So far, there are no interfaces to primary systems to access a patient's electronic medication plan, for example, and integrate a complete medication list into DOQUVIDE accordingly. This not only has a negative impact on data quality, but also on the acceptance of the treating physicians. In addition to their primary system, they have to install, access and operate an additional application system, the inSuite DOQUVIDE. Even if the event forms to be filled out are designed to be as simple as possible, manual data entries are still required, which takes time that is rarely available in the daily practice routine.
The integration of telemedicine into healthcare is often discussed as the ultimate solution for relieving the healthcare system. Where do you see the greatest advantages, but also possible risks, when it comes to the increased use of telemedicine in the care of the chronically ill?
As already mentioned, telemedicine offers many advantages for the care of chronically ill people. One of the biggest advantages is improved access to care. Patients, especially those in rural or underserved areas, can receive regular care without long travel times. This is particularly important for patients with limited mobility or older patients. In addition, telemedicine can improve healthcare itself by enabling continuous monitoring of health parameters. This “real-time monitoring” can help to detect health deterioration at an early stage and avoid hospitalizations. In this way, telemedicine contributes in particular to prevention and diagnostics, but can also be used in therapy, for example to control the performance of therapeutic exercises. Another advantage lies in patient-centered care. Digital tools promote self-management and personal responsibility among patients by providing a better overview of the course of their illness. Furthermore, resources on the patient and practitioner side can be reduced or used more efficiently. Particular potential can be seen in the use of AI for the automated evaluation of data obtained through telemedicine, also in combination with clinical data. One key challenge is to ensure data protection and data security. The sensitive health data of chronically ill patients is an attractive target for cyber attacks, which is why the highest security standards are required. In addition, the digital divide could pose a problem, since not all patients have the technical devices or skills to use telemedicine effectively. This particularly affects older or socioeconomically disadvantaged groups. Another risk is the potential depersonalization of care. Purely digital interaction could weaken the personal doctor-patient relationship, which is an important part of therapy for many patients. Furthermore, it must be ensured that the quality of care does not suffer. It is important to note that telemedicine should never replace established treatment procedures and, in particular, practitioners; it should only supplement them.
What has changed in recent years in the area of regulation, quality assurance and data protection in the context of digital health care?
A key regulatory advance was the introduction of the Digital Care Act (DVG) in Germany. It enables doctors to prescribe digital health applications (DiGA) such as apps on prescription. This has not only promoted the use of digital tools in patient care, but has also created a clear framework for their approval. For example, in the DiGA Fast Track process, manufacturers must prove that their applications have a positive effect on patient care. These regulatory requirements make a decisive contribution to quality assurance. In the area of quality assurance, there is also a greater focus on evidence-based medicine. Digital applications must not only be functional, but also medically effective and safe. Standards such as the Interoperability Directive promote the integration of different systems, thus improving the exchange of data between stakeholders in the healthcare system. In the area of data protection, the introduction of the General Data Protection Regulation (GDPR) has set new standards throughout Europe. It defines strict requirements for the processing of sensitive health data and strengthens patients' rights, for example by requiring consent and transparent information about the use of their data. For digital health applications and telemedical solutions, this means that the highest security standards, such as encryption, access controls and regular security audits, must be adhered to. Despite this progress, challenges remain, particularly in the area of practical implementation. The balance between promoting innovation and strict regulation is a delicate one, as excessive requirements can delay the market launch of new technologies. Interoperability and standardization are also still being developed to enable the use of digital health solutions across the board.
You are also a member of the “Digitalization in Healthcare” committee of the German Medical Association. What role does politics play in implementing digital health solutions, and how closely do medical experts and political decision-makers work together to support this transformation?
Policymakers play a central role in the implementation of digital health solutions because they create the legal and financial framework that enables or hinders innovation while ensuring the safety and quality of care. Through legislative initiatives such as the Digital Care Act (DVG) or the Hospital Future Act (KHZG), policymakers have provided decisive impetus for the greater integration of digital technologies into healthcare. It promotes both the development and the introduction of new solutions, for example, through targeted funding for digital infrastructure and technologies in hospitals. Cooperation between medical experts and political decision-makers is essential for a successful digital transformation. In committees such as the German Medical Association's “Digitalization in Healthcare” committee, physicians work closely with political decision-makers to incorporate their practical experiences and perspectives into the design of laws and regulations. This collaboration ensures that digital health solutions are not only technically innovative, but also suitable for everyday use and patient-centered. Despite these efforts, collaboration often remains challenging. The speed at which political decisions are made sometimes conflicts with the dynamics of technological development and the requirements of medical practice. It is therefore important to further intensify the dialog between stakeholders and ensure flexibility in implementation.
Telemedicine has the potential to change healthcare in the long term. How do you see the future of telemedicine, especially with regard to the aging society, and what new technologies do you think could make a difference for the chronically ill?
Telemedicine will play an increasingly important role in the future, especially in the context of an aging society. With the increase in chronic illnesses and the growing need for continuous medical care, telemedicine offers solutions for making healthcare more efficient and patient-oriented. It can help to ensure medical care in rural areas, shorten waiting times and facilitate access to specialized medical services. For older people, who often suffer from multiple illnesses and require regular care, telemedicine offers enormous relief. With digital consultations and telemedical monitoring, they can remain in their familiar surroundings and still receive close monitoring of their health parameters. This not only improves their quality of life, but can also reduce the need for hospital stays and emergency care. New technologies could further accelerate this change. Wearables and sensors, for example, enable continuous monitoring of vital signs such as heart rate, blood pressure or oxygen saturation. These devices, combined with artificial intelligence (AI), can analyze health data and detect early warning signs of critical conditions. AI-based systems could also help doctors create personalized treatment plans and identify patterns in health data that would be difficult to detect manually. Another forward-looking field is robot-assisted telemedicine. Robots could be used not only for remote monitoring but also in home care to support older people with everyday tasks or to remind them to take their medication. Virtual and augmented reality could also be used in telemedicine, for example for rehabilitation programs that patients can carry out from the comfort of their own homes. Despite all the opportunities, challenges remain. Older people in particular need support in using digital technologies, and not everyone has access to stable internet connections or the necessary equipment. In addition, data protection and data security are key issues that are becoming even more important with the increasing use of telemedicine and sensitive health data.
*DOQUVIDE: Documentation of quality in the collection of vital parameters using implanted devices
**CHARISMHA study: opportunities and risks of health apps (CHARISMHA) | BMG