A telemedicine center enables the monitoring and care of patients remotely by means of telemedicine. A telemedicine center thus pursues the goal of providing medical services like diagnostics and therapy across spatial distances as promptly as possible by means of electronic health services. The establishment of telemedicine centers is currently gaining momentum in Germany1. The associated potential and the definition of the processes are explained below.

Potential of telemedical services

Telemedicine services can close the growing gap between treatment needs and the current supply of care. Telemedicine centers play a central role, as they support comprehensive and timely patient care.

Telemonitoring is the remote monitoring of a patient’s health status for the purpose of medical diagnosis, therapy and monitoring. Telemonitoring is conducted with the help of external or implanted sensor devices through digital communication channels.

From a medical point of view, the early detection of a deterioration in the health status of heart failure patients and the timely initiation of therapeutic measures are useful. Both are feasible through telemonitoring. Scientific evidence is provided by the studies TIM-HF-22 and IN-TIME3, which showed a significant reduction in all-cause mortality and hospitalization time through patient monitoring with highly structured telemonitoring.

Telemonitoring could also prove useful for other indications. For example, in a study conducted by Wurzer, Spielhagen et al., about 90 percent of admitted COVID-19 patients reported that they would have delayed hospitalization further if they had not been part of the study4. In-ear sensors were used to remotely monitor the study participants’ vital signs during the illness period and to provide early medical attention if their health deteriorated. The TELECOVID study conducted by the Klinikum rechts der Isar (Technical University of Munich) also suggests that telemonitoring using external sensors can be a reasonable solution, especially for monitoring COVID-19 patients5.

In addition to reliable data from remotely monitored patients, however, structured therapeutic action based on regulated perceived diagnostic information is also crucial for effective telemonitoring. Thus, in the sense of “remote patient management”, telemedically supported, structured, networked and mostly intersectoral anchored care is the requirement for the effectiveness of telemedical concepts6.

Telemedicine centers as new service providers

The German National Association for Digital Healthcare (“Spitzenverband Digitale Gesundheitsversorgung”) sees the establishment of telemedicine centers as service providers for telemonitoring as crucial to ensuring comprehensive care7. Driven by the possibility of a Uniform Evaluation Standard (German EBM) billing for telemonitoring in advanced heart failure (since 2022) telemedicine centers are currently being established Germany-wide (see list below).

Telemedical care of patients requires cooperation between physicians who primarily treat patients and make therapy decisions (e.g., family physicians, cardiologists) and a telemedical center that provides the remotely gathered data. The newly billable telemonitoring is carried out via telemetry-capable implanted devices, such as event recorders, pacemakers, implantable cardioverter/defibrillators and implants for cardiac resynchronization or via external sensor technology, such as blood pressure monitors and body scales, electrocardiograms or medical wearables (e.g. In-ear sensors).

Organizational anchoring of the telemedicine centers

How telemedicine centers can be anchored organizationally, i.e., who performs the telemonitoring service, can be regulated in different ways. For example, the telemedicine center can appear as an external service provider. In this case, it is a legally and economically independent company. In addition, the telemedicine center can be located in a hospital. In this case, there is a professional and organizational link between the two entities. As a third form, the telemedicine center can be operated by a physician network consisting of an association of general practitioners and/or specialists in private practice.8

Procedure of telemonitoring with telemedicine centers

The telemedicine center is responsible for instructing and informing patients about telemonitoring and the use of the devices, as well as for their technical equipment. The device that records the patient’s vital signs transmits the data to the responsible telemedicine center. There, the data is stored on an electronic platform and assessed by medical staff using medical history data such as age, gender, concomitant diseases, risk factors and medications. In the event of an abnormal finding, the telemedicine center either communicates with the treating physician and patient within 24 hours, depending on the severity, or can refer the patient directly for inpatient treatment. The aim is to intervene as soon as possible to prevent a worsening of the disease and the possible need for an ongoing inpatient treatment (see Fig. 1).

The tasks of a telemedicine center can only be performed by qualified cardiologists.

Information processes in telemedical care.

Fig. 1: Information processes in telemedical care.
Nach: Thomas M. Helms, Christian A. Perings et al. (2021): Positionspapier zur Zertifizierung von Telemedizinzentren. In: Kardiologe https://doi.org/10.1007/s12181-021-00522-4, Angenommen: 24. November 2021.

Billing of telemedical services

As described above, the range of billable telemonitoring services is currently limited to patients with advanced heart failure (NYHA-II or -III)9. In the future, further telemedical services are to be included in the guidelines and in the catalog of services of the health insurance companies and thus in the standard care.

Calculation example based on a fictitious use case

In general, the GOP billing of telemedical services is extrabudgetary and is thus remunerated at fixed prices. The following is a billing example for the telemedical care of a patient with advanced heart failure for one quarter. In this case example, it is assumed that the patient has advanced heart failure. The primary care physician (PBA) performs the examination and indication. As part of the telemedicine care, the patient receives an external measuring device for monitoring the heart rate. For this, the PBA provides guidance to the patient on the use of the device used and relevant aspects of self-management. The PBA exchanges information with the TMZ in charge. The TMZ’s tasks include reviewing alerts that require action and re-clarifying findings that cannot be assessed. In the case of alerts with a possible need for medical action, the TMZ informs the PBA on the same day.

To note: In this fictitious example, an attempt is made to make a calculation that is as practical as possible. Due to the novelty and currently still changing circumstances in the billing of telemedical services, no binding calculations can be made at this point. Depending on the existing conditions, the billings and thus the potential amounts may vary significantly.

Telemedicine care for patients with advanced heart failure

GKV: GOP billing telemonitoring heart failure (general practitioner)

Billings from PBA

  • Indication (15 minutes): EUR 7.3210 x 3 = EUR 21.96
  • Communication with the responsible TMZ: EUR 14.42

The PBA can bill for telemedicine services in the amount of EUR 36.38 in this example shown.

Billings from TMZ

  • Guidance and education: EUR 10.70
  • Telemonitoring by means of external measuring devices: EUR 236.59
  • Weekend surcharge (external meter): EUR 26.48
  • Patient’s equipment (flat rate): EUR 68.00

The TMZ can bill for telemedicine services of EUR 341.77.

In addition, there is an expense reimbursement for the approval processes of contract physicians for health insurance (“bureaucracy cost determination11“) of EUR 26.35.

A detailed list of the individual positions incl. GOP numbers, points and amounts can be found here: Telemonitoring in advanced heart failure reimbursable since 2022

Quality assurance of telemedicine centers

The agreement on quality assurance of telemonitoring in heart failure is not yet in place and should be urgently regulated according to the Telemonitoring Working Group of the German Society for Cardiology, Heart and Circulation Research e. V. (Deutsche Gesellschaft für Kardiologie-, Herz- und Kreislaufforschung e. V. (DGK))12. The working group has published proposals on the basic structural features of a telemedicine center13. To ensure structural and process quality of medical care, workflows should comply with recognized standards and norms. According to the proposals, regular qualified observation and perception of alarm messages from telemonitoring (year-round 24-h service) must be ensured. Likewise, an evidence-based, guideline-oriented therapy by the primary treating physicians must be ensured, which is supplemented by the cardiology specialists working at the telemedicine center through findings-based interventions. In order to ensure the quality of medical care, it is also essential that the medical staff at the telemedicine center is appropriately qualified and receives regular, specialized training. A regulation of such certification is thus inevitable to ensure quality.

In addition, the working group emphasizes that process flows within a telemedicine center should also be strengthened in the future through the use of artificial intelligence (AI)14. With the help of a corresponding algorithm, for example, the early detection of a deterioration in the state of health and the resulting early decision-making is possible (e.g. PolyScore of the TELECOVID study).

Which telemedicine centers already exist?

In the following, planned and already operating telemedicine centers or providers of telemedicine services in Germany and Austria are listed15. This includes telemedicine centers that use EBM billing for telemonitoring in heart failure as well as those that offer telemonitoring independently.

cosinuss° collaborates with the following telemedicine service providers in the form of studies and pilot projects:

Telemedicine centers in operation:

Telemedical centers using EBM billing for telemonitoring in heart failure:

Telemedical centers that offer telemonitoring independent of EBM billing:

Provider of infrastructure and services in the field of telemedicine

This article was last updated: June 29, 2022

Autor*innen / Authors

  • M.A. Kommunikationswissenschaft und Online-Marketing-Expertin mit Schwerpunkt auf Gesundheits- und Wissenschaftskommunikation. // M.A. Communication Studies and online marketing expert with a focus on health and science communication.

Quellen / References

  1. Status: April 2022
  2. Köhler F, Köhler K, Deckwart O et al (2018) Efficacy of telemedical interventional management in patients with heart failure (TIM-HF2): a randomised, controlled, parallel-group, unmasked trial. Lancet392:1047–105
  3. Hindricks G, Taborsky M, Glikson M et al (2014) Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): A randomised controlled trial. Lancet384:583–590
  4. Wurzer D, Spielhagen P, Siegmann A, Gercekcioglu A, Gorgass J, et al.: “Remote monitoring of COVID-19 positive high-risk patients in domestic isolation: A feasibility study”. PLOS ONE 16(9), 2021.
  5. M. Baldinger, et al.,“TELECOVID: Remote Vital Signs Monitoring of COVID-19 Risk Patients in Home Isolation With an In-Ear Wearable“ in IEEE Pervasive Computing, vol. 20, no. 02, pp. 58-62, 2021.
  6. Thomas M. Helms, Christian A. Perings et al. (2021): Positionspapier zur Zertifizierung von Telemedizinzentren. In: Kardiologe https://doi.org/10.1007/s12181-021-00522-4, Angenommen: 24. November 2021.
  7. POTENZIALE DER TELEMEDIZIN FÜR EINE BESSERE VERSORGUNG NUTZEN (2022): Positionspapier des Spitzenverbands Digitale Gesundheitsversorgung e. V. (SVDGV) https://digitalversorgt.de/wp-content/uploads/2022/02/Positionspapier-Potenziale-der-Telemedizin.pd
  8. Thomas M. Helms, Christian A. Perings et al. (2021): Positionspapier zur Zertifizierung von Telemedizinzentren. In: Kardiologe https://doi.org/10.1007/s12181-021-00522-4, Angenommen: 24. November 2021
  9. Prerequisites for the billing of telem. Care are: There is NYHA-II or NYHA-III stage heart failure with an ejection fraction < 40%. The patient has an implanted cardiac device (ICD, CRT-P, CRT-D) or has been hospitalized for cardiac decompensation in the past year. Heart failure is treated according to guidelines. There are no identifiable factors that prevent or jeopardize the transmission of monitoring data or that would hinder the patient’s self-management (https://www.kbv.de/media/sp/2020_12_17_RMvV_37_anerkannt_Telemonitoring_Herzinsuffizienz_BAnz.pdf ).

  10. Can be charged per full five minutes and a maximum of three times in case of illness.
  11. 2020-12-17_MVV-RL_Telemonitoring-Herzinsuffizienz_TrG.pdf [Internet]. [cited 11. April 2022]. Available at: https://www.g-ba.de/downloads/40-268-7196/2020-12-17_MVV-RL_Telemonitoring-Herzinsuffizienz_TrG.pdf
  12. Thomas M. Helms, Christian A. Perings et al. (2021): Positionspapier zur Zertifizierung von Telemedizinzentren. In: Kardiologe https://doi.org/10.1007/s12181-021-00522-4, Angenommen: 24. November 2021.
  13. Helms TM, Stockburger M, Köhler F, Leonhardt V, Müller A, Rybak K et al. Grundlegende Strukturmerkmale eines kardiologischen Telemedizinzentrums für Patienten mit Herzinsuffizienz und implantierten Devices, Herzrhythmusstörungen und erhöhtem Risiko für den plötzlichen Herztod. Herzschrittmacherther Elektrophysiol 2019; 30(1): 136-142. AUS: https://www.g-ba.de/downloads/40-268-7196/2020-12-17_MVV-RL_Telemonitoring-Herzinsuffizienz_TrG.pdf
  14. Thomas M. Helms, Christian A. Perings et al. (2021): Positionspapier zur Zertifizierung von Telemedizinzentren. In: Kardiologe https://doi.org/10.1007/s12181-021-00522-4, Angenommen: 24. November 2021.
  15. Status: April 2022. This list does not claim to be complete and will be continuously expanded.