What is a video consultation and why do I need it?

The medical side

Visiting the doctor is often a challenge, especially if you are ill or not mobile. According to the 2014 Physician Monitor, general practitioners have an average of about 7.5 minutes per patient. This makes it difficult to make house calls, especially in rural areas. Video consultations often provide a solution to this problem, not least thanks to the electronic certificate of incapacity to work (eAU) and e-prescriptions. If a personal video consultation and the secure transmission of documents are not sufficient, assistants (VERAH or NäPa) can make house calls with telemedical support to obtain necessary findings or carry out therapies. Doctors can also receive support from specialists via telemedical consultations. Such advanced telemedicine solutions are also based on video consultation systems. Patients can often be spared the trip to the doctor's office, while medical availability is not reduced by travel time.

The financial side

Video consultations are largely settled with the statutory health insurance companies via the EBM reimbursement system. While a telephone conversation can only be charged with the number 01435 (approx. €10.50), a video consultation can even be charged to the insured person or basic flat rate (approx. €30/quarter) and approx. €15 per 10 minutes of conversation time. A detailed overview of remuneration is provided by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV). Further remuneration models are available, for example, within the framework of the HZV contracts (in each case in Appendix 3, especially for the use of telemedical care assistants). Video consultations with private patients can also be billed via the fee schedule for doctors (Gebührenordnung für Ärzte, GoÄ). The German Medical Association has issued a list of recommendations for this, although it should be noted that, unlike in the case of care provided by health insurance funds, no requirements are placed on the telemedicine solutions.

The regulatory side

In order for video consultations to be covered by health insurance, they must be carried out using certified systems. This is due to a paragraph in the 5th Social Security Code (Section 365 SGB V), which requires a joint technical solution from the various stakeholders on the service provider and cost unit side. The resulting requirements are set out in Appendix 31b of the Federal Master Contract for Doctors of the National Association of Statutory Health Insurance Physicians (KBV) and must be validated by an independent, accredited body for each video consultation solution. A certificate of compliance with information technology security and data protection is required in each case. The KBV maintains a list of all certified video consultation providers.

As part of the data protection audit, the providers of video consultations must explain exactly which personal data is processed on which legal basis (Art. 6 DGSVO), how the rights of the data subjects (Chap. 3 DSGVO) are complied with and how data that is no longer required is deleted. Since medical data is a special category of personal data (Art. 9 GDPR), a data protection impact assessment (Art. 35 GDPR) must be carried out to demonstrate that appropriate technical and organisational measures are in place to reduce the risk to data subjects to an acceptable level.

The technical side

At their most basic level, video consultations allow a secure video conversation between a doctor and their patient. Patients must be able to use the service without registering or installing software. To ensure adequate IT security, it is required that data communication takes place directly between the participants of the consultation without a central server (‘peer-to-peer’) and is encrypted according to the state of the art in line with BSI specifications. The audio and video connection must be adaptive to the available bandwidth. It must not be possible for providers to view any of the content of the consultation hours, and metadata may only be processed for technical purposes for a maximum of three months. The insertion of advertising is prohibited. In addition, penetration tests carried out by IT security service providers listed by the BSI must be used to regularly validate that the video consultation does not pose any serious security risks (OWASP Top 10).

In practice, these requirements are usually implemented by means of the following system specifications:

• Provision of the video consultation solution in the form of a web app. Additional native apps can also be provided, but on their own they do not meet the requirements for installation-free use.
• Temporary patient access in the form of alphanumeric TANs or one-time passwords.
• Data exchange between participants via WebRTC-based, end-to-end encrypted communication channels negotiated directly between the participants, without the use of a central video server. STUN and TURN servers are permissible if the participants are shown a corresponding warning when they use them.

Why does the video consultation need to be replaced?

Video consultations are very limited in their functionality. While a simple conversation is sufficient for many medical issues, in most cases more is needed. For example, medical image data or vital parameters have to be shared in real time and various medical IT systems have to be networked with each other. This widespread problem in telemedicine is approached by each manufacturer in their own way. These effort drivers not only make telemedicine systems more expensive because each provider has to develop their own solution, but also prevent them from being fully compatible and networkable. That is why a better basis for telemedicine is needed.

Conclusion

Video consultations are the basis for many telemedical applications in Germany today because their security and data protection compliance can be verified using a defined procedure and their billability is firmly regulated. Even for applications where patients are not the focus, video consultations are often used as a basis for communication. In practices, medical care centres and the emergency medical service, video consultations offer great potential for patients and medical staff. If you also want to introduce video consultations, or offer them to your customers, but don't yet know exactly how, we will be happy to help you.

If you want to learn more about the future of telemedicine and why it can and should already be the basis of your work and products, then read my next post about TI-Messenger.