Dr. med. Schäfer: KHZG — Digitisation from a Clinic´s Perspective

The objective behind the passage of the Future of Hospitals Act [Krankenhauszukunftsgesetz; KHZG] is to drive digitalization in hospitals and ensure that patients are the focal points of all efforts. Dr. Matthias Schäfer is medical coordinator at St. Franziskus Hospital Eitorf in North Rhine-Westphalia; in his interview with Pascal Frank, he speaks about the challenges and achievements relating to this law. 

Detecon: If, after submitting the application for the investment funding, you think about the KHZG in a broad sense, what do you think has turned out to be especially successful?

Schäfer: The KHZG helped us to take a closer look at our own IT situation and consider how effective it was. Independently of the KHZG, we had already set ourselves the goal of creating a smart hospital, and so we had a digitalization strategy as well. Thanks to the KHZG, it became possible to realize some of ideas that, although already on our agenda, had previously not been feasible owing to a lack of funding. In terms of time, the KHZG set deadlines for us to define without delay a tangible and clear implementation concept. What is our ultimate destination, and what are currently the major weaknesses in our IT system if we want to achieve this or that goal? The structural specifications of the so-called “mandatory criteria” of the KHZG were very helpful in determining answers to these questions. We were then able to conduct a review that revealed the locations of gaps in the system and showed us what we needed to drive forward and with what priority to advance in the direction of our goal of the smart hospital.

On the 28th of October 2020, the Hospital Future Act (KHZG) came into force in Germany, an investment program designed to ensure more modern equipment and digitalized processes in hospitals. The federal government and federal states promote certain modernisation measures in this regard. Each federal state is entitled to a share of the total three billion euros provided by the federal government. Most of the states have already requested their demand reports for funding from the hospitals, and individual hospitals have already received their funding. By the end of 2021 at the latest, all applications for funding must be submitted by the states to the Federal Social Security Office (BAS).

What would you say did not go so well, and where do you see the greatest potential for optimization of future funding?

While obtaining the information about the funding criteria was initially a simple matter, precise details were absent in many areas. There was frequently a lack of clarity about what was meant because the formulation of the goals was highly abstract. Furthermore, it was first necessary to determine the extent to which the various providers would be able to meet the pertinent funding elements and criteria in their offers. The Detecon team was able to provide truly rapid and successful support during our collaboration.

Longer lead-in time overall and more accurate information regarding the realization of the KHZG would likely have been useful. Certain issues arose because, although you began by pursuing a digitalization strategy, you soon ran into limitations such as mandatory criteria and financing constraints that forced you to compromise in various areas. Many points presume a certain basic infrastructure before this type of system with funding elements can be realized at all — there must frequently be a weighing of priorities and financial feasibility in these cases. This can also result in funds flowing in the wrong direction. I suspect that we are not the only hospital that had to take considerations like these into account during our preparation of the application for funding.

In addition to the funding, installment payments will be due starting in 2024 if the minimum level of digitalization has not been achieved. What do you think about this? Is this an effective approach?

Despite the imposing funding amount of almost €4.5 billion, the threat of installment payments will become a relative one as not all hospitals are in a position to realize the core criteria. I am assuming for the time being that the installment payments will not be feasible. The investments required to implement multiple funding requirements are so high that they often exceed the allocated budget. Our initial application was only a fraction of what we were later allocated as a grant budget. We were at first delighted when the funding budget was set three times higher than the amount requested in the actual application. In the course of preparing the application, however, we made many corrections and in the end, we were able to include only one single funding element in the application that could be realized with this budget. We almost ended up making our decision on the basis of affordability and not of the element that had actually been prioritized. Financing and allocation are not necessarily oriented to need — a different yardstick should be applied according to circumstances.

Larger hospitals, hospital chains, or university hospitals, some of which are also affected by this, have per se completely different investment volumes at their disposal for the digitalization process. We can assume that the need for investment in IT infrastructure is greatest in smaller basic and standard care hospitals. And yet the hospitals that have the greatest need in this respect are allocated a lower volume because of their size. Essentially, the leap to a digital hospital is equally expensive for everyone. The number of workstations or the number of access points are not the most significant cost factors, which are instead found in the basic investments. Accordingly, such factors are the main cost drivers in the financing budget so that there is often no money left over for other elements.

I would think that smaller hospitals have the same issues that we do. Only a part of the major funding elements 2 to 6 can be realized. If the KHZG is to make any sense, the issue of harmonizing the IT as a whole should be paramount. There cannot be any hospitals that have digitalized everything. If the electronic patient file cannot be provided by smaller clinics because certain elements are not feasible, even digitalization on a larger scale in the collaboration is of no use and a part of the investments comes to nothing.

To what extent would it have made sense to provide funding for basic investments before setting such extensive mandatory criteria?

This was exactly what occurred to us. It would certainly have made sense to define a certain basis first. This is originally the intent behind the mandatory criteria, but in reality an ideal-typical vision became the fundamental requirement to obtain any funding at all. If the mandatory criteria had been expressed a little more flexibly, which would have made them more realistic, or if there had been an examination of the fundamental infrastructure on which the criteria are based, basic funding would have been the better path. The mandatory criteria would have ultimately been adapted and their partial non-achievement would not have been directly classified as detrimental to funding. This would have resulted in the realization of several funding elements and the achievement of an overall homogeneous level of digitization. Now we have the problem that there are one or two funding elements in hospitals that satisfy the criteria almost completely and the other elements are at zero. Perhaps a more realistic idea would have been to have, say, three of the elements at a level of 60 to70 percent rather than one at 100 percent.

If you had had one wish during the application and implementation process, what would it have been?

The possibility to submit a statement that, depending upon the specific situation, would have relativized the mandatory criteria.

What do you expect the basic hospital landscape in Germany to look like at the conclusion of this campaign, i.e., after 2025, in terms of digitalization?

Digital communication between hospitals will certainly simplify and accelerate many things — discharge management, for instance — and that makes perfect sense. Nevertheless, I am skeptical that the objective of employing the many criteria to increase patient involvement (when checking in, for example) will be achieved.

There is certainly a segment of the population that competently uses smartphones and digital media and is used to checking in electronically. But you also have to carry along the clientele who are not necessarily so well versed in digital options. These are still the people who represent the majority of our patients, and I’m not sure how secure and comfortable they will feel if they encounter a digital-only hospital.

So I don’t necessarily think digitalization offers a strategic advantage in patient acquisition right now. That may certainly be different in a few years. We must “sell” to the patients the idea that digital structures are available at all. Where digitalization accelerates and simplifies processes — in employees’ daily workflow, for instance — the rise in effectiveness will be much greater. I think it is still too early to regard patients as the focal point of digitalization, whether now or in 2025.

Would you recommend this type of funding to other countries in Europe?

I fundamentally believe that investments in digitalization are the right step and are necessary. Nevertheless, the aim should be organic growth, and that is an evolutionary rather than a revolutionary process. At the moment, the KHZG is more of a revolution that doesn’t generate the kind of enthusiasm among everyone involved that will lead to a complete success.

Thank you for the interview!

Matthias Schäfer, MD, holds the position of medical coordinator at St. Franziskus Hospital in Eitorf. He also acts as a consultant to a number of hospitals during medical reorganization processes. After studying human medicine at the Johannes Gutenberg University in Mainz, he completed his specialist training in anesthesiology, intensive care medicine, emergency medicine, and pain management at the Clinic for Anesthesiology in 1998 and worked academically and clinically, most recently as managing senior physician, at the University Medical Center Mainz. During this period, he was in charge of a number of projects such as central personnel management, reorganization of OR management, and outpatient surgery. On behalf of the Ministry of the Interior of Rhineland-Palatinate, he developed the system of regional depositories for medicines and medical devices as well as an antidote depository in Rhineland-Palatinate (Central Emergency Depository for Disasters). In 2010, he became hospital director and assumed responsibility for three sites of the Clinic for Anesthesiology and Intensive Care Medicine of the Community Clinic of the Middle Rhine. In 2017, he accepted the position of leading senior physician for the DRK Krankenhausgesellschaft Thüringen-Brandenburg.

The interview was conducted by