Patients in Germany have been able to use telemedicine applications for well over a year now. In spring 2018, the German Medical Association decided to drop the blanket ban on long-distance treatment. In 2016, the Baden-Württemberg Medical Association (German: Landesärztekammer) was the first medical association in Germany to allow long-distance treatment by doctors under certain conditions in designated projects. This includes the docdirekt project, which started with a pilot trial run by the KVBW in Stuttgart and Tuttlingen last year. The KVBW is the first Association of Statutory Health Insurance Physicians in Germany to run such a trial.

What began as a pilot in certain areas was quickly expanded just six months later. Since October 2018, people insured under the statutory health insurance schemes from all over Baden-Württemberg can receive telemedical help for acute illnesses quickly and easily using docdirekt. The procedure is quite simple. Patients can use telemedicine services from Monday to Friday between 9 am and 7 pm either on a special app or by calling 0711 965 897 00, with their insurance card ready to provide insurance details to a medical assistant who records personal details and determines the level of urgency. The call will then be forwarded to an emergency centre in the case of a life-threatening emergency. If it is not a life-threatening emergency, the assistant will arrange a time for a doctor in charge to return a call, for example, as soon as possible, during the patient’s lunch break or in the evening, whenever it suits the patient. When the doctor returns the call, he or she will talk to the patient about the problem and give recommendations for treatment. However, if the doctor decides that the patient needs to physically see someone, the docdirekt team will book a doctor’s appointment in a GP’s or consultant’s practice.

The docdirekt team currently consists of 39 teledoctors who are general practitioners, internists or paediatricians. Among them is Dr. Martina Hartmann, who runs a general medical practice in Mannheim. She is very positive about the project: "I've experienced a lot of positive things so far," she says. "It is common knowledge that there is a shortage of doctors in many areas, and many other countries have already shown that telemedicine services such as docdirekt are an option to deal with this. If we compare ourselves with other European countries in the use of digital media in medicine, Germany is second to last.”

Hartmann has been involved in the regional pilot project since the start of docdirekt and has equipped her practice accordingly. If a patient needs telemedical help and calls or sends a message, the information appears on her mobile phone. If she can offer help at the specified period, she accepts the patient via an app. She can view all patient data on a laptop in one of her consultation rooms and then make a video or telephone call. An email is sent to her staff to inform them that a telemedical patient is being treated in this particular consultation room. "I can see the patient, look at the patient’s files, for example photos, and give instructions, such as ask him or her to move a limb, to get an idea of their condition. It is just like having the patient face-to-face in my consultation room,” says Hartmann. "Unfortunately, we cannot yet issue any prescriptions, referrals or disability certificates - this may be possible in the future. I document the telemedical consultation, and can provide feedback to the docdirekt medical assistant if I want them to make another call to the patient at a later date.” In general, check-up calls are made to the patient within eight days. These check-up calls are made for quality control reasons and will become part of the final evaluation beginning in April 2020.

Hartmann also points out that the feedback received from patients who have used the telemedicine services is very positive. “We deal with up to 10 patients a day on average, usually young or middle-aged, although occasionally older people contact us. A 70-year-old patient with blood pressure problems recently called us and we were able to give him advice telemedically. I adapted his drug dose to his condition. This particular patient therefore avoided a 35-km drive to the nearest doctor. Patients who are not sure what to do about wounds or insect bites use our service, as well as people with back, head or abdominal pain. We talk to them to find out what their problem is and provide good advice. Basically, anybody who is worried about his or her health can contact us. In some cases, of course, I have to refer patients to a practice or outpatient clinic for examination. This can be done by the docdirekt medical assistant, but often I do this myself. In this case, the patient is given my practice mobile number, so that he or she can contact me if necessary."

Dr. Thomas Finkbeiner, a paediatrician from Tübingen, has been part of the project from the outset. He had gained previous telemedicine experience in Africa. “At the moment, not that many people contact us about children’s health issues. This doesn’t yet happen on a daily basis, probably because docdirekt is not that well-known and people tend to see their family paediatrician when their child is sick. It’s something people do automatically, I think.” Finkbeiner says that people usually call when their own paediatrician is not available, for example on a Wednesday afternoon or a Friday night. He also emphasises that everybody can call instead of going directly to their doctor. "I think the advantage of using docdirekt is obvious, especially for people with children, as they can avoid spending hours with a sick child in a full waiting room where there is a variety of other pathogens. In at least half of the cases, telemedical consultations work very well.”

“Most users so far are from rural areas,” says Finkbeiner. “People usually have to travel quite a long way to see a doctor. It’s easier in cities.” He also points out that in rural areas, people are very positive about docdirekt. “I have seen a few patients on several occasions. The first telemedical appointment is usually the biggest hurdle for many patients as they do not know the online doctor. But once they have overcome this, many continue to use the service. Of course, teledoctors have to clearly communicate what they can and cannot do. It goes without saying that I cannot look into someone’s ears or check their lungs. If this is necessary, the children have to come to the practice. But I can usually give advice and help to the caller in a way that is not that different from visiting a doctor in person.”

“People call us for practically anything, it could be pimples or diarrhoea, colic or when a child has swallowed something,” says Finkbeiner, who regularly works as stand-in for other doctors in Germany and abroad. The consultations are mostly conducted by video, because this provides more information than a phone call would. "It gives me a good idea about a child’s condition and is far better than just talking on the phone. But doctors need a great deal of experience to save patients a trip to the practice. And of course, this must be remunerated accordingly, as we deliver high quality medical services."

Finkbeiner hopes that the next step will be offering telemedicine consultations at times when patients usually have to use accident and emergency facilities for unexpected health issues. “Most people with health problems need competent advice relatively quickly, and I don’t see why they should spend hours in the evenings or weekends at accident and emergency departments waiting for a doctor to see them. Docdirekt has huge potential in this area. I am sure it would help reduce the number of people that have to go to an emergency doctor.

In addition, in order to fully exploit the potential of docdirekt and other telemedicine services, something would have to be done about existing regulations. “Theoretically, people could also contact us when holidaying in other German regions or abroad. But strictly speaking, I am not allowed to officially provide advice in these cases, as docdirekt is only for patients that are actually present in the region for which docdirekt is destined, i.e. Baden-Württemberg in my case. In my opinion, the only thing that matters is where the doctor is, the location of the patient is secondary. This is just the start of these kind of services in Germany."