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Bordering on the Meuse-Rhine: cross-border care and restructuring at UKA

Marc Smith
Supervising Editor
Hospital Healthcare Europe

The continuing expansion of the EU has brought many geographical changes to the European landscape. But while the problems associated with policing these shifting borders are well documented, issues relating to cross-border healthcare remain mired in political and cultural uncertainty.  However, partnerships and alliances are being formed in an effort to widen the debate, which has so far focused on facilitating patient mobility, to deal with the nuts and bolts of delivering high-quality care to a pan-European clientèle, building regional networks and establishing European centres of reference.

Crossing national borders
The University Hospital Aachen (UKA), Germany, is one such institution to actively engage with a partner from across the border. Since 2004, UKA has had an alliance agreement with University Hospital Maastricht (azM), the Netherlands, which came into force on 8 June 2004.


“We have a comparatively small catchment area due to our geographic position,” says Professor Henning Saß, CEO of UKA, which is located just 30km from Maastricht. He compares their prealliance catchment area to a semicircle that has been completed thanks to the addition of Dutch and Belgian patients. “Before our cooperation with azM,” continues Saß, “German patients had far longer to travel for services that we were unable to provide, while Dutch patients had to endure waiting lists for elective surgery that we did not have.”

But patient care is not the only aim of the alliance. With increasing cost pressures and competition from private healthcare providers forcing both UKA and azM to look beyond their own four walls to better cope with these challenges, UKA had a problem; there was no other German university hospital in easy distance with which to form a constructive alliance – the nearest is over 70km away in Cologne. So, the boards of both hospitals decided to cross national borders to achieve their goals.


Legally, the contract signed between the two hospitals refers to the legislative framework as set out in European law for cross-border treatment. The rest of the contract regulates the fields of cooperation and financial arrangements for treating cross-border patients. Independently of the UKA–azM alliance, Germany’s largest health insurer has signed an agreement with its Dutch counterpart to enable their customers to choose a GP, specialist or hospital in either country, which has facilitated the process for patients.

The clinical areas in which the two hospitals are cooperating include high-end vascular surgery, nephrology, nuclear medicine, transplantation medicine and reconstructive surgery following breast cancer. By sharing expertise, combining resources and creating Euregional availability in these areas, they aim to develop European centres of reference. Since last October, Professor Michael Jacobs, head of vascular surgery at both hospitals, has been determined to do just that. As the first doctor from azM to work at both institutions, his work is split 60/40 in favour of azM, in recognition of the fact that UKA did not have an independent academic vascular surgery department a year ago. Every surgeon has their own contract and financial arrangement within their own hospital, but there are barriers to overcome. Despite being so close geographically, “attitudes, traditions and working mentalities differ enormously between the two hospitals”, admits Jacobs. But there is no room for parochialism at either department. “Everyone has to change towards international, open-minded thinking,” he warns, “but this is definitely going to work.”

Patient concerns
Although vascular surgery is an example of how sharing services across borders is working, patients will worry about the possibility of a well-functioning clinical service migrating to a nearby hospital with the result that it is discontinued in their own. While Saß sees no problem with some services being “weighted in favour of one hospital”, he does admit that discontinuation can happen in smaller disciplines, such as paediatric heart surgery, which is now performed only at UKA. The overriding principle, however, is that each hospital should function as an independent university hospital.

Another potential concern relates to hospital-acquired infections (HAIs) crossing the border along with the patient. “HAIs are a big problem,” admits Saß. “Although we have one of the lowest rates in Germany, our colleagues at azM have stricter protocols and are more successful than us in this area.” While this is undoubtedly a concern, the alliance means that UKA can more easily harmonise its procedures with those at azM.

Clinical and financial restructuring
It is not only patients who have been looking on with a slight sense of trepidation. For not only have staff at UKA had to absorb the changes brought about by the strategic alliance with azM; they have also had to be party to a massive restructuring within the hospital itself.

The reasons for this restructuring, which is both clinical and financial in nature, are threefold. First, there are the recent changes in German law to accommodate diagnosis-related groups (DRGs); secondly, there has been political pressure to reduce the average length of stay (ALoS) and hence the number of hospital beds; and thirdly, the promotion of day surgery to balance the above.

To help meet these challenges, UKA started work on developing an appropriate strategy in 2003. In late 2004 the hospital employed a private firm, Steria Mummert Consulting, to validate the concept and support its implementation. The main thrust of the clinical restructuring involved the establishment of interdisciplinary units (IUs) and clustering. IUs run alongside the traditional medical departments but are assigned to a relevant head of department. For example, previously there were four independent intensive care units for surgical patients (in cardiothoracic surgery, neurosurgery, general surgery and anaesthesiology), each with their own staff, protocols and equipment. Following the restructuring there is one intensive care IU for all surgical patients, with one director and fewer beds thanks to better bed occupancy and process improvement – those measures that improve organisational performance and maximise the quality of patient services.

Clustering is a similar strategy where corresponding procedures are grouped together to enable “standard care” treatments to be performed. For example, there is a “heart” cluster where cardiothoracic surgery, vascular surgery and general cardiology treatments are carried out, and a “head” cluster where the same happens for ENT, ophthalmology and dentistry procedures. Each individual department, however, retains a small number of beds for severe or difficult cases.

Economic restructuring focuses on a “Plan–Book–Pay” model. This gives department heads an annual budget – calculated from treatment revenues minus overhead costs – from which they plan how many patients they can treat and what equipment and staff they will need. Once this has been worked out, they book what they intend to use and pay for it out of their budget. The intention is that department heads will take on more responsibility, have more freedom and see increased transparency.

Business intelligence
Plan–Book–Pay requires department heads to access more and better data. With this in mind, UKA invested in business intelligence (BI) – “a broad concept encompassing the processes, software and technologies for gathering, storing, analysing and providing access to data to help users make better decisions”.(1)
In common with most hospitals, UKA uses one hospital management system in all clinical departments (in this case Medico, Siemens) and one for the business side (EIP, SAP). In addition, there is a laboratory information system (Swisslab), while a new system was required to take account of the introduction of DRGs. The problem with all this information was consistency – the different systems would produce separate reports that contained the same data but calculated different results. Rather than discussing how to best use this data to improve care, this culminated in discussions over the validity of the data itself. A further problem was the time it took to prepare the reports – often several weeks.

Instead of making changes to the systems already in place, Volker Lowitsch, UKA’s CIO, oversaw the introduction of SAS Business Intelligence in 2003. Designed as an overarching integration system, SAS Business Intelligence aims to support the executive board and clinical management in their planning and decision-making. In practice this means gathering and analysing data from the various systems to increase efficiency, improve effectiveness and reduce costs.

Lowitsch says the two key objectives of the new system were “to have a consistent database and to improve response times”. Consistency is guaranteed by the use of a balanced scorecard and the dedicated SAS data warehouse. “The result is that now we discuss the results and not the quality of the data,” says Lowitsch. Response times have improved so much that 80% of requests can now be answered within 24 hours – a vast improvement on the previous system. On the ground this has made a significant improvement in, for example, identifying the underutilisation of operating theatres, which benefits patients by reducing waiting times.

SAS Business Intelligence also helps with controlling finance. In particular, DRGs have changed how healthcare is paid for in Germany, so that doctors now have to record individual care episodes and the hospital then bills the Krakenkassen, the body that ultimately pays for the treatment. SAS Business Intelligence helps to ensure greater liquidity, which minimises losses on interest payments – an important consideration given that UKA bills the Krankenkassen for approximately €1 million per day.

Lowitsch believes that part of the new system’s success is to be found in its transparency. “Before, clinicians would talk about their results but could not prove it. Now we have a reporting system that is accessible to everyone so people can compare how they are doing with their colleagues,” he says.

Treatment on diagnostic street
One person who many doctors would like to compare themselves with is Professor Rolf Günther, UKA’s chairman of radiology. As one of the most respected figures in the field, Günther presides over one of the most up-to-date radiology departments in Europe – a treasure trove of the most advanced equipment to diagnose and treat a vast array of complications.

On the interventional side, the department is divided into vascular and nonvascular. Günther has been involved in vascular interventions since the 1970s, in particular balloon angioplasty and stents. But something that is particularly special to UKA is the inferior vena caval (IVC) filter designed by Günther himself. In deep vein thrombosis, blood clots can migrate to the pulmonary vasculature, which may lead to life-threatening pulmonary embolism (PE). To prevent this, a cone-shaped steel filter with anchoring struts was designed to be inserted percutaneously into the IVC, preventing major emboli from migrating. Developed to be retrievable after an average of 14 days, more recently they have been modified to stay in the body for up to a year. Today it is known as the Günther Tulip (Cook Medical) and has a large market share worldwide. In the US, for example, 50–60,000 people benefit from caval filters every year. In Europe, where there are many patients with recurrent PE despite receiving adequate anticoagulation, the device is essential in preventing mortality.

Diagnostic radiology has improved dramatically over the last decade, and UKA offers the whole spectrum: MR, CT, ultrasound and X-ray. Günther is particularly proud of the “diagnostic street” that forms the heart of diagnostic radiology at the hospital. At one end of the street there is conventional X-ray, which leads, through a series of interconnecting doors, to more precise diagnostic machines and finishes with the most cutting-edge technology, such as the new Dual Source CT scanner (Siemens). Günther believes that CT “has developed into the most important modality, which is surprising given that people were predicting it had reached the end of the road after the advent the MR!”

As a leading university hospital, UKA carries out a lot of research, particularly heart and coronary vessel visualisation. Both CT and MR are used in this pursuit, but the Dual Source scanner enables Günther and his team to overcome the movement of the coronary vessels and heart thanks to residual motion being eliminated, which enables a clear image of a single heartbeat to be captured.

At the heart of medical technology
Sharing the same campus as the main hospital, RWTH Aachen University is part of the research and teaching arm. The Helmholtz Institute for Biomedical Engineering Aachen (HIA), led by Professor Thomas Schmitz-Rode, leads the research into the development and implementation of biohybrid systems.  Schmitz-Rode believes that medical technology has an important role to play in the future of healthcare, particularly in patient monitoring. Economic restrictions, political pressure to reduce ALoS and demographic changes guarantee that medical technology’s ability to save costs will be utilised on a much wider scale than it is at present. “Our innovations are our oil,” says Schmitz-Rode, “We have to be innovative, develop and export these innovations for the good of our health system.”

There are many products that HIA is developing, from tissue-engineered valves and myocardial patches to oxygenators and totally artificial hearts. However, one of the most commercially advanced projects is the range of blood pumps invented at the institute. One such device, a miniature blood pump designed to fit into the tip of catheter for left ventricle support without the need for thoracotomy, is awaiting FDA approval. The product was the basis for a spinoff company, Impella, which is based in Aachen.

“We have a network of cooperation with industry partners,” says Schmitz-Rode, “with funding from the German Federal Ministry of Education and Research and the German Research Council, allied to that given by private investors.” With this in mind, an important part of the training that students receive is based around project management skills. “Development and implementation – those are the key words,” insists Schmitz-Rode.

Looking to the future, Schmitz-Rode sees three aspects that will strongly influence medical technology: miniaturisation, computerisation and molecularisation. However, the outcomes of these developments will not appear right away. Schmitz-Rode and his team are working to five- or 10-year strategies and he admits that, in the short term, it will not be cheap. “In the long run there will be cost reductions as patients will not need as many operations as they do now”, which is something that both senior managers and patients can look forward to.


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