Digitalization poses novel challenges to health care systems worldwide by supporting – in some cases, sometimes radically – changing existing mindsets, processes and structures 25, 26.
In this case, OVCs were introduced as a supporting link between orthopedic specialists, GPs and patients in a defined health region in eastern Germany to improve existing processes in the clinic/rural region interfaces in patient care.
In the existing approach, an overall positive conclusion could be drawn. The patients and doctors involved were, for the most part, very satisfied with the use of OVCs, in accordance with existing international data 27. At the same time, the percentage frequency of use of OVCs, in relation to the total population of military patients treated in the outpatient clinic, was even slightly above the data of other international study data on OVCs at 9% 6. The process analysis of the roll-out experience revealed several benefits and challenges, as discussed below.
As an implication for the regional establishment and expansion of offering OVCs in a (supra)regional health region, it seems sensible to map this within the framework of a process organization to enable spatial and temporal structuring of the processes as a basis for an organizational structure. To do so, responsibilities and strategic goals for OVCs need to be clearly defined and controlled in advance.
In the described case, Alfred D. Chandler's credo "structure follows strategy" was not fully followed 28. While the goals and identification of resources were initially set, it was not possible to fully align the structure of the clinic and patient pathways in OVCs within the framework of this pilot project. It must therefore be discussed whether "strategy follows structure" does not apply, since the OVC project grew out of the recognized and addressed potential for the improvement of existing processes in the Bundeswehr Medical Service.
Total quality management was used as an important component for process optimization. Its application has often been successfully used to improve processes in the health sector 29 and represents an important framework structure in the presented project.
In the project, however, fixed setup structures were not initially established according to a traditional organizational approach 30, as the extent of use and implementation was not initially foreseeable. When planning an expansion of OVCs to other locations, a systematic definition of the processes of an OVC should take place for easier implementation 31.
In addition, a concrete process cost analysis 10 with a comparison of not only the costs (caused by travel/waiting time, personnel expenditure and technology for the implementation of OVCs) but also the revenue from online appointments and, in the medium and long term, with regard to the quality of treatment. If applicable, patient acquisition should be taken into account.
The involvement of staff in the sense of change management concepts, e.g., according to Kotter, should take place from the very beginning when introducing digital innovations in health care companies. According to the experience gained here, the implementing facilities can do without a permanent additional expenditure of personnel with the corresponding additional costs. Existing outpatient clinic staff can manage the organizational operation of online video consultations well based on the experience gained, especially if an online appointment booking system is linked to the respective hospital information system 32. For a period of approximately 2 months, however, personal contact and supervision by a competent "facilitator" who is familiar with the system should be possible (e.g., from the provider company or from the system environment) to be able to immediately address procedural questions or problems and thus promote acceptance and willingness to use the system. In addition, staff should be provided with training and handouts, as well as email and telephone advice and support.
Using the example of regional cooperation between GPs and clinic outpatient departments ("local" hospitals), a new form of digital telemedical integrated care structures in a health region can be envisaged for the future. The described project can be considered a population-based model for a regional network 33. Here, the exchange and cooperation between outpatient and inpatient care providers, general practitioners and specialists is digitally enabled. In this concept, military doctors act as gatekeepers for the Bundeswehr, which is especially important in rural areas with only a few regional hospitals compared to urban areas. In addition to networking through OVCs, digital communication channels such as email traffic and digital interfaces for the rapid transmission of images and findings between practices and hospitals must be created in parallel.
In health care companies with clinical and practice components, the use of OVCs and other digital services could further strengthen the idea of a company network as a cooperative patient-oriented overall system and bring the individual elements closer together 34. This form of creating proximity through direct collegial consultative exchange was also positively emphasized by medical users within the framework of the current project. In this way, specialized medical providers could benefit the patients entrusted to them in the best possible way. At the same time, current professional standards could be safely used on a broad scale 35.