[Potential of a Telemedical, Inpatient-Outpatient Care Concept to Improve the Quality of Healthcare from the User's Perspective - An Acceptance Analysis of the TELnet@NRW Study]. / Potential eines telemedizinischen, sektorenübergreifenden Versorgungskonzeptes zur Qualitätssteigerung der Gesundheitsversorgung aus Nutzersicht ­ eine Akzeptanzanalyse der TELnet@NRW Studie.

OBJECTIVE: The aim of this study was to measure the acceptance of a telemedical, inpatient-outpatient care concept by physicians, patients and the relatives of patients. Based on a quantitative survey of acceptance, both the potential and success factors influencing the use of telemedicine were to be highlighted. METHODS: The TELnet@NRW study is a national, multicenter, cluster-randomized study in stepped-wedge design conducted from February 2017 to January 2020 for the purpose of documenting changes in the quality of care through telemedicine in an inpatient-outpatient network. Consultations were focused on intensive care medicine and infectious diseases. This current study used questionnaires for specific groups of patients to determine acceptance of the telemedical care concept practiced in the main study. The survey was anonymously conducted once in either digital or paper-based form during the reporting period. RESULTS: The answers of 126 questionnaires from physicians and 1686 questionnaires from patients and their relatives were evaluated. The physicians of both sectors attributed high potential (up to 88.4%) for telemedicine to improve guideline-adherent treatment. A trustworthy and appreciative communication during the telemedical consultation represented a positively reinforcing success factor. The additional workload generated by telemedicine inhibited acceptance, especially in the inpatient sector. A continuation of telemedicine beyond the end of the project was supported by the majority of surveyed physicians (inpatient 60.6%, outpatient 82.1%) as well as in patients and their relatives (inpatient 79.7%, outpatient 57.4%) in both sectors. CONCLUSION: There is widespread acceptance of telemedical, inpatient-outpatient care concepts among physicians, patients and their relatives. Low-effort processes and user-centered technology are crucial to increase the rate of use. Telemedicine has the potential to improve the quality of care and can serve as a robust component of sustainable healthcare in Germany.

An Innovative Telemedical Network to Improve Infectious Disease Management in Critically Ill Patients and Outpatients (TELnet@NRW): Stepped-Wedge Cluster Randomized Controlled Trial.

BACKGROUND: Evidence-based infectious disease and intensive care management is more relevant than ever. Medical expertise in the two disciplines is often geographically limited to university institutions. In addition, the interconnection between inpatient and outpatient care is often insufficient (eg, no shared electronic health record and no digital transfer of patient findings). OBJECTIVE: This study aims to establish and evaluate a telemedical inpatient-outpatient network based on expert teleconsultations to increase treatment quality in intensive care medicine and infectious diseases. METHODS: We performed a multicenter, stepped-wedge cluster randomized trial (February 2017 to January 2020) to establish a telemedicine inpatient-outpatient network among university hospitals, hospitals, and outpatient physicians in North Rhine-Westphalia, Germany. Patients aged ≥18 years in the intensive care unit or consulting with a physician in the outpatient setting were eligible. We provided expert knowledge from intensivists and infectious disease specialists through advanced training courses and expert teleconsultations with 24/7/365 availability on demand respectively once per week to enhance treatment quality. The primary outcome was adherence to the 10 Choosing Wisely recommendations for infectious disease management. Guideline adherence was analyzed using binary logistic regression models. RESULTS: Overall, 159,424 patients (10,585 inpatients and 148,839 outpatients) from 17 hospitals and 103 outpatient physicians were included. There was a significant increase in guideline adherence in the management of Staphylococcus aureus infections (odds ratio [OR] 4.00, 95% CI 1.83-9.20; P<.001) and in sepsis management in critically ill patients (OR 6.82, 95% CI 1.27-56.61; P=.04). There was a statistically nonsignificant decrease in sepsis-related mortality from 29% (19/66) in the control group to 23.8% (50/210) in the intervention group. Furthermore, the extension of treatment with prophylactic antibiotics after surgery was significantly less likely (OR 9.37, 95% CI 1.52-111.47; P=.04). Patients treated by outpatient physicians, who were regularly participating in expert teleconsultations, were also more likely to be treated according to guideline recommendations regarding antibiotic therapy for uncomplicated upper respiratory tract infections (OR 1.34, 95% CI 1.16-1.56; P<.001) and asymptomatic bacteriuria (OR 9.31, 95% CI 3.79-25.94; P<.001). For the other recommendations, we found no significant effects, or we had too few observations to generate models. The key limitations of our study include selection effects due to the applied on-site triage of patients as well as the limited possibilities to control for secular effects. CONCLUSIONS: Telemedicine facilitates a direct round-the-clock interaction over broad distances between intensivists or infectious disease experts and physicians who care for patients in hospitals without ready access to these experts. Expert teleconsultations increase guideline adherence and treatment quality in infectious disease and intensive care management, creating added value for critically ill patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT03137589; https://clinicaltrials.gov/ct2/show/NCT03137589.

[Digital Based Intensive Care Networks]. / Digital gestützte intensivmedizinische Versorgungsnetzwerke.

The Corona pandemic is a clear demonstration of the need for an alternative to face-to-face medicine. This demand makes telemedicine the tool of choice. In the preliminary stage of the Virtual Hospital North Rhine-Westphalia (VKh), tele-intensive care consultation services have contributed to both a benefit in terms of care and a benefit for individual patients. The task now is to roll out and use digitally-supported intensive-care networks across the board, including throughout Europe. The goal of telemedicine is to ensure comprehensive patient care - also across sector boundaries of the healthcare system - and to improve quality. Tele-intensive care is already an evidence-based added value and addresses current and future challenges such as resource shortage and citizen-centered care. The Virtual Hospital NRW is a telemedical network structure that is unique in Germany. It provides telemedical services from expert centers in a quality-assured and comprehensive manner for general hospitals as well as for outpatient players. Telemedical services help to overcome rigid sector boundaries and to optimize treatment processes. As a result, service-differentiated care networks are goal-oriented. The medium-term perspective could be cross-border network structures. Medical expertise and also intensive care data, both from care and research, could thus be used throughout Europe. In October 2021, the Aachen Expert Center reported on its first 112 telemedically co-managed COVID-19 patients as part of the preliminary stage of the virtual hospital. With a lethality rate of 34.2% in the group of ventilated severely ill COVID-19 patients and a transfer rate of 8%, high-quality care close to the patient's home was achieved through tele-intensive medical consultation services.

Decision-Making Authority During Tele-ICU Care Reduces Mortality and Length of Stay-A Systematic Review and Meta-Analysis.

OBJECTIVES: Although the current coronavirus disease 2019 pandemic demonstrates the urgent need for the integration of tele-ICUs, there is still a lack of uniform regulations regarding the level of authority. We conducted a systematic review and meta-analysis to evaluate the impact of the level of authority in tele-ICU care on patient outcomes. DATA SOURCES: We searched MEDLINE, EMBASE, CENTRAL, and Web of Science from inception until August 30, 2020. STUDY SELECTION: We searched for randomized controlled trials and observational studies comparing standard care plus tele-ICU care with standard care alone in critically ill patients. DATA EXTRACTION: Two authors performed data extraction and risk of bias assessment. Mean differences and risk ratios were calculated using a random-effects model. DATA SYNTHESIS: A total of 20 studies with 477,637 patients (ntele-ICU care = 292,319, ncontrol = 185,318) were included. Although "decision-making authority" as the level of authority was associated with a significant reduction in ICU mortality (pooled risk ratio, 0.82; 95% CI, 0.71-0.94; p = 0.006), we found no advantage of tele-ICU care in studies with "expert tele-consultation" as the level of authority. With regard to length of stay, "decision-making authority" resulted in an advantage of tele-ICU care (ICU length of stay: pooled mean difference, -0.78; 95% CI, -1.46 to -0.10; p = 0.14; hospital length of stay: pooled mean difference, -1.54; 95% CI, -3.13 to 0.05; p = 0.06), whereas "expert tele-consultation" resulted in an advantage of standard care (ICU length of stay: pooled mean difference, 0.31; 95% CI, 0.10-0.53; p = 0.005; hospital length of stay: pooled mean difference, 0.58; 95% CI, -0.04 to 1.21; p = 0.07). CONCLUSIONS: In contrast to expert tele-consultations, decision-making authority during tele-ICU care reduces mortality and length of stay in the ICU. This work confirms the urgent need for evidence-based ICU telemedicine guidelines and reveals potential benefits of uniform regulations regarding the level of authority when providing tele-ICU care.

[Quality Improvement in Intensive Care Through Telemedicine: the TELnet@NRW Example]. / Qualitätssteigerung in der Intensivmedizin durch Telemedizin: Beispiel TELnet@NRW.

The German health care system faces the great challenge of ensuring high-quality and comprehensive health care in the future as the shortage of physicians continues to grow. Telemedicine-supported healthcare networks, which guarantee access to specialized medical expertise close to the patient's home and tailored to their needs, and thus to high-quality patient-centered treatment, could provide a solution. The TELnet@NRW best-practice project provides a blueprint for expert teleconsultations and put them into practice. TELnet@NRW demonstrated that expert teleconsultations improve interdisciplinary exchange and thus increase quality and efficiency in healthcare. With the widespread telemedical network as a new structure of the healthcare system, TELnet@NRW enabled a more efficient use of existing resources. TELnet@NRW was funded in the first phase of the Innovation Fund. The experts from the two university hospitals in Aachen and Münster provided daily expert teleconsultations to the 17 cooperating hospitals and two physician networks. A 24/7/365 availability was provided, accompanied by training for doctors and nursing staff aimed at improving evidence-based care. Communication took place via an encrypted audio-video conferencing system and the certified data exchange platform FallAkte Plus. The aim of TELnet@NRW was to establish a cross-sectoral telemedical network as a new digital form of care. A total of > 150 000 patients were included. With TELnet@NRW, a major step towards future-proof healthcare was taken, and for us this means providing patients with high-quality care close to patients' homes. This is currently being used as the conceptual basis for the Virtuelles Krankenhaus NRW as a possible solution for the continuation of former project services.

Telemedicine in Germany During the COVID-19 Pandemic: Multi-Professional National Survey.

BACKGROUND: In an effort to contain the effects of the coronavirus disease (COVID-19) pandemic, health care systems worldwide implemented telemedical solutions to overcome staffing, technical, and infrastructural limitations. In Germany, a multitude of telemedical systems are already being used, while new approaches are rapidly being developed in response to the crisis. However, the extent of the current implementation within different health care settings, the user's acceptance and perception, as well as the hindering technical and regulatory obstacles remain unclear. OBJECTIVE: The aim of this paper is to assess the current status quo of the availability and routine use of telemedical solutions, user acceptance, and the subjectively perceived burdens on telemedical approaches. Furthermore, we seek to assess the perception of public information quality among professional groups and their preferred communication channels. METHODS: A national online survey was conducted on 14 consecutive days in March and April 2020, and distributed to doctors, nurses, and other medical professionals in the German language. RESULTS: A total of 2827 medical professionals participated in the study. Doctors accounted for 65.6% (n=1855) of the professionals, 29.5% (n=833) were nursing staff, and 4.9% (n=139) were identified as others such as therapeutic staff. A majority of participants rated the significance of telemedicine within the crisis as high (1065/2730, 39%) or neutral (n=720, 26.4%); however, there were significant differences between doctors and nurses (P=.01) as well as between the stationary sector compared to the ambulatory sector (P<.001). Telemedicine was already in routine use for 19.6% (532/2711) of German health care providers and in partial use for 40.2% (n=1090). Participants working in private practices (239/594, 40.2%) or private clinics (23/59, 39.0%) experienced less regulatory or technical obstacles compared to university hospitals (586/1190, 49.2%). A majority of doctors rated the public information quality on COVID-19 as good (942/1855, 50.8%) or very good (213/1855, 11.5%); nurses rated the quality of public information significantly lower (P<.001). Participant's age negatively correlated with the perception of telemedicine's significance (ρ=-0.23; P<.001). CONCLUSIONS: Telemedicine has a broad acceptance among German medical professionals. However, to establish telemedical structures within routine care, technical and regulatory burdens must be overcome.

[Citizen-centred health care in Germany: An analysis of expert interviews]. / Bürgerzentrierte Gesundheitsversorgung in Deutschland ­ eine Analyse von ExpertInneninterviews.

BACKGROUND: Citizens can represent a relevant key resource in health care, for example by actively practicing preventive health care and managing their own health care needs. In Germany, the role of citizens in the health care system has not yet been defined. Therefore, the aim of this study is, as a first step, to determine what is meant by "citizen-centred healthcare", since there is, as yet, no clear definition. METHODS: Between September and November 2022, semi-structured expert interviews were conducted with representatives from the fields of politics and self-administration and service providers and, with their consent, recorded and transcribed. A category system was developed inductively and deductively based on Mayring's content analysis. Using this, two members of the project team coded the interviews independently of each other using the QCAmap software. After a replication check of the deviations, the content could then be analyzed. RESULTS: A total of n = 10 interviews were conducted (n = 3 service providers, n = 2 self-administration, n = 5 politicians). The analysis revealed two different understandings of citizen-centred healthcare. Some of the experts understand citizen-centred healthcare as care that is provided close to home and easily accessible for citizens. The others interpret the term as care where citizens take on an active role. All interviewees saw the lack of health literacy among citizens as a key challenge. The social imbalance, which creates an inequality of opportunity in the involvement of citizens, was also mentioned several times. Opportunities were generally understood as the possibility of conserving resources and maintaining health. The analysis shows that there is still a lack of solutions that specifically address these challenges as well as the implementation of citizen-centred health care. DISCUSSION: The expert interviews demonstrate that there are two fundamentally different understandings of citizen-centred healthcare and how it should be established in Germany. Future research should therefore pursue the goal of developing a definition of "citizen-centred health care" by expert consensus. This can then form the basis for concrete, future goals for action. There was consensus among the experts regarding the problems that need to be considered in this context. Factors such as citizens' lack of health literacy and social imbalance should therefore be given more attention in the future.

Comparison of Drug-Related Problems in COVID-19 and Non-COVID-19 Patients Provided by a German Telepharmacy Service for Rural Intensive Care Units.

Telepharmacy is used to bridge the persisting shortage of specialist ward-based pharmacists, particularly in intensive care units (ICU). During the coronavirus disease 2019 (COVID-19), pharmacotherapy was rapidly developed, which resulted in multiple changes of guidelines. This potentially led to a differing risk for drug-related problems (DRPs) in ICUs. In this study, DRPs were detected in telepharmacy consultations of a German state-wide telemedicine network for adult patients in rural ICUs. The analysis included ICUs of ten general care hospitals with a total of 514 patients and 1056 consultations. The aim of this retrospective, observational cohort study was to compare and analyze the DRPs resulting from ICU patients with or without COVID-19. Furthermore, known risk groups for severe COVID-19 progression (organ insufficiency [kidney, liver], obesity, sex, and/or older age) were investigated with their non-COVID-19 counterparts. As a result, in both groups patients with acute renal insufficiency and without renal replacement therapy showed a significantly higher risk of being affected by one or more DRPs compared to patients with normal renal function. In COVID-19 patients, the initial recommendation of therapeutic anticoagulation (ATC-code B01AB 'Heparin group') resulted in significantly more DRPs compared to non-COVID-19 patients. Therefore, COVID-19 patients with therapeutic anticoagulation and all ICU patients with renal insufficiency should be prioritized for telepharmacy consultations.