[Digital health applications (DiGA) in the area of tension between progress and criticism : Discussion paper from the "Digital health" specialist group of the German Informatics Society]. / Digitale Gesundheitsanwendungen (DiGA) im Spannungsfeld von Fortschritt und Kritik : Diskussionsbeitrag der Fachgruppe "Digital Health" der Gesellschaft für Informatik e. V.

Since December 2019, digital health applications (DiGA) have been included in standard care in Germany and are therefore reimbursed by the statutory health insurance funds to support patients in the treatment of diseases or impairments. There are 48 registered DiGA listed in the directory of the Federal Institute of Drugs and Medical Devices (BfArM), mainly in the areas of mental health; hormones and metabolism; and muscles, bones, and joints. In this article, the "Digital Health" specialist group of the German Informatics Society describes the current developments around DiGA as well as the current sentiment on topics such as user-centricity, patient and practitioner acceptance, and innovation potential. In summary, over the past three years, DiGA have experienced a positive development, characterized by a gradually increasing availability of various DiGA and coverage areas as well as prescription numbers. Nevertheless, significant regulatory adjustments are still required in some areas to establish DiGA as a well-established instrument in long-term routine healthcare. Key challenges include user-centeredness and the sustainable use of the applications.

Why should stakeholders consider the effect of tensions in collaborative innovation in healthcare-lessons learned from surveying integrated care projects in Germany.

INTRODUCTION: The German Innovation Fund supports projects that aim to improve healthcare through integration and intersectoral collaboration. As is typical for collaborative innovation projects, partners often pursue different objectives, which can create tensions and affect outcomes. The study aims to explore the causes and effects of tensions in integrated care projects and how frameworks, processes, and management should be designed to deal with tensions and achieve their productive effects. METHODS: In an online survey we asked participants about the causes, effects, and management of tensions and their implications for integrated care projects (n = 58 completed questionnaires). We applied bivariate descriptive statistics to analyse the quantitative data. RESULTS: Tensions between stakeholders, caused by deep-seated differences and the design of the project frameworks, often affect the course and outcome of innovative integrated care projects. However, through appropriate conflict management and negotiation processes such tensions can be managed constructively and lead to better outcomes. DISCUSSION: Tension is usually seen as something unpleasant to be avoided and/or overcome. In fact, tensions can have positive effects, the importance of which remains little understood. Developing appropriate frameworks for managing and integrating different perspectives are key factors in unlocking the positive potential of tensions in integrated care projects.

Tensions between the Professions: How Integrated Care Can Benefit from Better Understanding and Managing Conflicting Perspectives and Demands.

In the transition from fragmented to integrated care, tensions are inevitable. Contradictions between the actors of the different professions involved can have negative but also positive effects on change processes in the healthcare system. This is especially true for integrated care, where collaboration among the workforce is pivotal. Therefore, efforts should not be made to avoid tensions from the outset, if this is at all possible, but to deal with them constructively. The attention of leading actors must be increased to recognize, analyse, and successfully manage tensions. The creative potential of tensions can be harnessed to successfully implement integrated care and engage the diverse workforce.

[The maturity model for the public health service-a tool for assessing and improving the digital maturity level of German public health agencies]. / Das Reifegradmodell für den Öffentlichen Gesundheitsdienst ­ Ein Instrument zur Erfassung und Verbesserung des digitalen Reifegrades von deutschen Gesundheitsämtern.

The COVID 19 crisis has highlighted the key role of the public health service (PHS), with its approximately 375 municipal health offices involved in the pandemic response. Here, in addition to a lack of human resources, the insufficient digital maturity of many public health departments posed a hurdle to effective and scalable infection reporting and contact tracing. In this article, we present the maturity model (MM) for the digitization of health offices, the development of which took place between January 2021 and February 2022 and was funded by the German Federal Ministry of Health. It has been applied since the beginning of 2022 with the aim of strengthening the digitization of the PHS. The MM aims to guide public health departments step by step to increase their digital maturity to be prepared for future challenges. The MM was developed and evaluated based on qualitative interviews with employees of public health departments and other experts in the public health sector as well as in workshops and with a quantitative survey. The MM allows the measurement of digital maturity in eight dimensions, each of which is subdivided into two to five subdimensions. Within the subdimensions a classification is made on five different maturity levels. Currently, in addition to recording the digital maturity of individual health departments, the MM also serves as a management tool for planning digitization projects. The aim is to use the MM as a basis for promoting targeted communication between the health departments to exchange best practices for the different dimensions.

What can healthcare systems learn from looking at tensions in innovation processes? A systematic literature review.

BACKGROUND: Until now, scholarship on innovation processes in healthcare systems lack an in-depth appreciation of tensions. Tensions often revolve around barriers and result from individual assessments and prioritizations that guide actions to eventually overcome these barriers. In order to develop a more differentiated understanding of tensions' role in healthcare innovation processes, this paper aims to shed light on the multifaceted ways in which tensions emerge, are being dealt with, and how they hinder or, at times, facilitate innovation processes. METHODS: A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The review involved searching three databases for original research articles and manually searching citations. Twenty-nine original full texts were identified, evaluated, and coded. These include papers on innovation in healthcare systems that investigated innovation-related organizational tensions. The findings were synthesized into different types of tensions in healthcare system innovation and the descriptions of the conflicting elements. We also analyzed the investigated innovations by type, process stages, and across different countries and healthcare systems. RESULTS: A total of forty-two tensions were identified and grouped into nine categories. Organizing tensions were predominant, followed by learning/belonging, performing, and performing/organizing tensions. Tensions most frequently occurred in the implementation phase and in the form of a dilemma. Included studies were conducted mainly in government-funded healthcare systems. CONCLUSION: Our data suggest that innovation processes in healthcare systems are impaired by conflicts between contradictory elements, working cultures, and convictions and the organizational and regulatory context. Since the majority of the tensions we collected in our study can be addressed, future policy-making and research should take advantage of this fact and develop strategies that significantly influence the successful management of tensions and thus improve the implementation of innovations.

Instruments to measure outcomes of post-intensive care syndrome in outpatient care settings - Results of an expert consensus and feasibility field test.

BACKGROUND: There is no consensus on the instruments for diagnosis of post-intensive care syndrome (PICS). We present a proposal for a set of outcome measurement instruments of PICS in outpatient care. METHODS: We conducted a three-round, semi-structured consensus-seeking process with medical experts, followed each by exploratory feasibility investigations with intensive care unit survivors (n1 = 5; n2 = 5; n3 = 7). Fourteen participants from nine stakeholder groups participated in the first and second consensus meeting. In the third consensus meeting, a core group of six clinical researchers refined the final outcome measurement instrument set proposal. RESULTS: We suggest an outcome measurement instrument set used in a two-step process. First step: Screening with brief tests covering PICS domains of (1) mental health (Patient Health Questionnaire-4 (PHQ-4)), (2) cognition (MiniCog, Animal Naming), (3) physical function (Timed Up-and-Go (TUG), handgrip strength), and (4) health-related quality of life (HRQoL) (EQ-5D-5L). Single items measure subjective health before and after the intensive care unit stay. If patients report new or worsened health problems after intensive care unit discharge and show relevant impairment in at least one of the screening tests, a second extended assessment follows: (1) Mental health (Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder Scale-7 (GAD-7), Impact of Event Scale - revised (IES-R)); (2) cognition (Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Trail Making Test (TMT) A and B); (3) physical function (2-Minute Walk Test (2-MWT), handgrip strength, Short Physical Performance Battery (SPPB)); and (4) HRQoL (EQ-5D-5L, 12-Item WHO Disability Assessment Schedule (WHODAS 2.0)). CONCLUSIONS: We propose an outcome measurement instrument set used in a two-step measurement of PICS, combining performance-based and patient-reported outcome measures. First-step screening is brief, free-of-charge, and easily applicable by health care professionals across different sectors. If indicated, specialized healthcare providers can perform the extended, second-step assessment. Usage of the first-step screening of our suggested outcome measurement instrument set in outpatient clinics with subsequent transfer to specialists is recommended for all intensive care unit survivors. This may increase awareness and reduce the burden of PICS. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov (Identifier: NCT04175236; first posted 22 November 2019).

The German health care Innovation Fund - An incentive for innovations to promote the integration of health care.

PURPOSE: Many health systems face challenges such as rising costs and lacking quality, both of which can be addressed by improving the integration of different health care sectors and professions. The purpose of this viewpoint is to present the German health care Innovation Fund (IF) initiated by the Federal Government to support the development and diffusion of integrated health care. DESIGN/METHODOLOGY/APPROACH: This article describes the design and rationale of the IF in detail and provides first insights into its limitations, acceptance and implementation by relevant stakeholders. FINDINGS: In its first period, the IF offered € 1.2 billion as start-up funding for model implementation and evaluation over a period of four years (2016-2019). This period was recently extended to a second round until 2024, offering € 200 million a year as from 2020. The IF is triggering the support of relevant insurers for the development of new integrated care models. In addition, strict evaluation requirements have led to a large number of health service research projects which assess structural and process improvements and thus enable evidence-based policy decisions. ORIGINALITY/VALUE: This article is the first of its kind to present the German IF to the international readership. The IF is a political initiative through which to foster innovations and promote integrated health care.

Sharing Frailty-related information in perioperative care: an analysis from a temporal perspective.

BACKGROUND: Especially patients older than 65 years undergoing surgery are prone to develop frailty-related complications that may go far beyond the index hospitalization (e.g., cognitive impairment following postoperative delirium). However, aging-relevant information are currently not fully integrated into hospitals' perioperative processes. METHODS: We introduce a temporal perspective, which focuses on the social construction of time, to better understand existing barriers to the exchange of frailty-related data, targeting complexity research. Our chosen context is perioperative care provided by a tertiary hospital in Germany that has implemented a special track for patients over 65 years old undergoing elective surgery. The research followed a participatory modelling approach between domain and modelling experts with the goal of creating a feedback loop model of the relevant system relationships and dynamics. RESULTS: The results of the study show how disparate temporal regimes, understood as frameworks for organizing actions in the light of time constraints, time pressure, and deadlines, across different clinical, ambulant, and geriatric care sectors create disincentives to cooperate in frailty-related data exchanges. Moreover, we find that shifting baselines, meaning continuous increases in cost and time pressure in individual sectors, may unintentionally reinforce - rather than discourage - disparate temporal regimes. CONCLUSIONS: Together, these results may (1) help to increase awareness of the importance of frailty-related data exchanges, and (2) impel efforts aiming to transform treatment processes to go beyond sectoral boundaries, taking into account the potential benefits for frail patients arising from integrated care processes using information technology.

Transition from in-hospital ventilation to home ventilation: process description and quality indicators.

The current demographic development of our society results in an increasing number of elderly patients with chronic diseases being treated in the intensive care unit. A possible long-term consequence of such a treatment is that patients remain dependent on certain invasive organ support systems, such as long-term ventilator dependency. The main goal of this project is to define the transition process between in-hospital and out of hospital (ambulatory) ventilator support. A further goal is to identify evidence-based quality indicators to help define and describe this process. This project describes an ideal sequence of processes (process chain), based on the current evidence from the literature. Besides the process chain, key data and quality indicators were described in detail. Due to the limited project timeline, these indicators were not extensively tested in the clinical environment. The results of this project may serve as a solid basis for proof of feasibility and proof of concept investigations, optimize the transition process of ventilator-dependent patients from a clinical to an ambulatory setting, as well as reduce the rate of emergency re-admissions.

Business evolution or revolution? Mail-order pharmacies in Germany.

It is an interesting detail of the present reform of national public health service in Germany that mail-order and internet pharmacies will be founded in future as new (e-commerce) business models. Main points of conceivable business systems can be characterised as well as critical success factors. No potential participant can ever have all the necessary resources and competences to implement a competitive business system without external support. This is why cooperation seems to be a useful tool for competence management. The Resource-based View will serve as theoretical background for analysis. The required and available competences of conceivable players can be identified. Features of resources can be described that recommend special types of cooperation with the intention of establishing and operate a business system. Especially German and international pharmaceutical wholesalers can be identified as conceivable "parents" of mail-order pharmacies in the future.