KHZG realization in Hesse. A conversation with Mathias Raab and Niko Ringelstein

The majority of hospitals have submitted their applications for the funding pursuant to the Future of Hospitals Act [Krankenhauszukunftsgesetz; KHZG]. In some places, such as at the Gross-Gerau District Hospital in Hesse, administrations are now poised to begin realization. An interview with Mathias Raab, Process and Project Management, and Niko Ringelstein, Head of IT, with Consultant Pascal Frank from Detecon.

Detecon: Looking back, what is your opinion of nationwide funding on such a large scale?

Ringelstein: It’s a good idea and a necessary measure because there is a lot of catching up to do when it comes to digitalization. The realization, however, has proved to be a bit bumpy and, in my opinion, has been a little rushed by lawmakers; we initially had very little information.

Raab: That’s much the way I see it. If we elaborate a little further, it speaks volumes that something like the KHZG with funding of this magnitude has come from the federal government in the first place. Investments like this are actually a matter for the federal states. We are delighted that an investment structure like this has been created. Realistically, however, this can only be the beginning. Projects of this type incur various follow-up costs for maintenance, employee systems, applications, etc. Things are off to a good start, but federalism in the negative sense has come back to haunt us. Every federal state has its own rules. More specific information was not forthcoming until after the application had been submitted. Nevertheless, it worked out quite well in Hesse.

What has been the most positive feature?

Raab: The funding criteria and priorities were clearly set. This approach gave the hospitals a clear picture of what lawmakers had envisioned, and they were able to move forward actively, driving projects and identifying gaps in the system. This has significantly accelerated general digitalization efforts.

Ringelstein: The various funding criteria were categorized and there was a focus on specific and essential areas. This can be seen, for example, in the proportionate and mandatory IT security costs — a very important aspect.

  • Degree in health economy (University of Bayreuth)
  • Employed for over ten years in a number of hospitals varying in size and with various operators
  • Focus on project and process management/in-house consultant

To what extent has the depth of the funding criteria been chosen correctly — AI or cloud topics as examples?

Ringelstein: The KHZG was set up for Germany as a whole. That meant defining the topics broadly enough to enable everyone to fund something. Hospitals that have already reached a relatively high level of digitalization are also supposed to benefit from the KHZG.

Raab: It is not completely clear to me what the funding criteria are actually based on. I suspect that there were some reference materials in the ministry that led to this orientation and focus. Still, I am not aware of any survey specifically asking hospitals about the status quo of their level of digitalization. All you ever hear in Germany is that we are lagging behind. I personally am not aware of any actual studies that convincingly reveal that. We are a district hospital with a manageable budget and relatively far advanced in digitalization, at least in some areas such as Wi-Fi and tablets. Some of the funding criteria were a good fit and we sifted out what was relevant for us — but we don’t have any contact with AI and robotics, for example.

“Digitalization in health care is failing primarily because of the financing system and a lack of incentives.” - Mathias Raab

What points of the KHZG do you think deserve criticism?

Ringelstein: I always had the feeling that we never really knew exactly what we were supposed to do. Various questions arose. How and when exactly must the application be submitted? What all has to be included with it? What can be submitted at a later date? The applications are seeking huge amounts of money, so these are also existential issues for the hospitals. After all, they want the application to be approved.

Raab: Quite frankly, we can admit that we would have failed miserably without external support. The lawmakers required the support of certified IT consultants in designing or preparing the applications for certain things. Still, a lot of time and energy had to be invested in the preparation of an acceptable application, and despite external support, questions about some of the points came back. It’s inconceivable for me that any hospital could actually have run this gauntlet successfully completely on their own.

  • Trained IT specialist for system integration
  • Has been working in hospital IT since 2000
  • Since 2011 in the IT department of the District Hospital
  • Since September 2020, head of the IT department of the District Hospital

After the projects have been realized, payment reductions will become effective in 2025 and later if the minimum level of digitalization has not been achieved. What do you think about that?

Raab: I can certainly understand this approach. The question is whether threats are useful or whether it is better to reward those who actively do something. Generally speaking, it is a mystery to me why it seems to be so difficult to utilize government funding in Germany. We have repeatedly seen legislative processes in the past when funding was made available, but never utilized. So some form of leverage might not be a bad idea.

Ringelstein: The question for me is to what extent this will be checked. Who will measure the degree of achievement, and how exactly will it be done?

How is the general mood about this in other clinics?

Raab: I know of hospitals that wanted to invest even more and for whom the funding did not go far enough. I take the stance that it has to be viewed as no more than a beginning and that such a fund should be made available at intervals of two years. Other hospitals probably have similar ideas, especially when it comes to the IT sector, where technology becomes obsolete so quickly.

To what extent has the KHZG helped your hospital?

Ringelstein: At the moment, we are just starting the realization, but it appears to have definitely helped even now. There are points that were already on the agenda, but without the KHZG, we probably would not have achieved this improvement in some areas.

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

Raab: Detailed guidelines would have helped a lot. What is needed in what form and what is the required lead time. Providing concrete details about the requirements retroactively was a disaster for the course of the entire process.

Ringelstein: Optimally, we should have been given another half-year to prepare, and then we could have gotten off to a really good start. That would also have been beneficial for the optimization of the online portals and for the upload of the applications.

If there are no further regulations, what do you expect for the hospital landscape after 2025?

Raab: I at least hope that the hospitals will carry on with the projects afterwards. Ultimately, however, it will always come down to funding. When managing directors see that the funds are not there, they will start turning the austerity screws and projects will be scrapped. The message to politicians is this: You’re off to a good start, but the federal government should invest funds continuously while earmarking them for the digitalization of the health care system.

Thank you very much for the interview!

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).

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