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Switzerland introduces TarMed for hospitals and primary care

A new federal medical tariff, known as TarMed, is creating a wave of demand across Switzerland for new hospital and primary care software.

Introduced in January this year, TarMed replaces local healthcare-funding arrangements made by the Swiss cantons with a single federal scheme. It institutes a detailed body of disease and therapy codes, and requires a rigorous audit system. In addition, TarMed introduces strict new regulations for doctors, allowing them only to practice in those areas in which they have been fully certified by central federal authority. As part of the new regulations, primary care doctors must adopt new software systems that not only record each transaction and session, but also regulate the authorised competence of the doctor in each disease area.

Effect on hospital systems

Many hospitals are finding that their systems also need updating to comply with the new TarMed regulations. Hospitals need to track all goods from purchase right through to use, in order to claim funds back from the federal authorities under TarMed. The federal government also wants this information in order to assess the cost of treatment under each disease code.

A typical example is the Cantonal Hospital at Basel. To comply with TarMed, the hospital is having to upgrade its purchasing-records system at the cost of over 500 000 Swiss francs (approx €146 000).

Changes in primary care

The new regulations have sparked a dash to join the Swiss family doctors’ association, the FMH. This is because the Government will only refund treatments to medical practitioners who are registered under the FMH to the relevant level of competence. The FMH has found that not only is its membership burgeoning, but that there is a rush to complete training courses that had been started years ago and never officially finished.

According to an interview with two primary care doctors about the new regulations published in the St Galler Tagblatt, the introduction of the new software has been complex and expensive. The typical cost of the new application to a practice is around €3000. Since GPs will not be refunded for treatment without the new software, they have no choice but to buy it.

The software is also complicated, and some of the coding definitions are prompting protests by doctors. The coding system incorporates some 4600 different items, although only about 100 are common and only 30–40 of these are typically used by a primary care doctor in everyday practice.

A number of different checks are built into the software. If a doctor begins to treat a patient against a code not covered by his Dignitaet, or state-registered level of competence, the computer displays an alarm. It also includes a procedure known as the Validator, which double-checks all calculations against relevant items in the database — to ensure correct drug prescriptions are given — and data held in the database.

The new software has proved popular with patients. Many doctors are using the system to help educate their patients into healthier living. The system can call up figures on target blood pressure, weight and diet appropriate for the individual patient.

Doctors find some aspects of the new system questionable, however — such as the way it handles testing charges and emergency situations.

The costs of tests such as ECGs, diagnostic imaging and blood tests are a major budget item for family doctors, and many use local facilities for most of these tests. But the TarMed software currently only registers tests if carried out in certain major testing centres; local test centres have yet to be added to the system. This is a major inconvenience and is causing disruption in many practices.

Another problem Swiss doctors have with the TarMed application is the way it handles emergency situations, particularly those that occur in the practice. Doctors argue that if a patient suffers an emergency episode while visiting a clinic/doctor’s consulting rooms — a quite common occurrence — then that episode should be treated as a separate item from a normal visit. Emergency episodes demand far more attention and time: besides first-aid treatment, an ambulance frequently has to be called and the patient cared for while waiting for it to arrive. Such episodes are severely disruptive of the day’s schedule. The TarMed software, however, does not distinguish between an emergency episode and a normal consultation. This has led to high-level meetings between doctors’ leaders and the funding authorities.

One aspect of the new system doctors do welcome is the ability to compare their costs with their colleagues. Previously, all they had to go on were the tariffs set out by the funding agencies. Single practices in particular are seeing this as particularly helpful, not only for the commercial benefit it gives them, but because they can compare themselves against the performance and range of services of other practices.

Data security

Data security has been a major issue with TarMed. Before its introduction, there was a major debate amongst doctors over just how data should be anonymised before being transmitted to the funding agencies, and just how easy it would be to reconstruct identity from details left in the anonymised healthcare record.

But from reports in the Swiss computer press, doctors’ own computers may be more vulnerable. One correspondent reports finding second-hand hard disks for sale with patients’ records still on it. Another computer specialist, who had installed TarMed systems, claimed that they offer poor security: doctors frequently use their PCs loaded with TarMed for browsing the Internet, and the software’s integration with Internet Explorer severely compromised patients’ healthcare records while the doctor was online. He also said that TarMed’s disease coding was completely open within the system, and that identifying details of a patient’s medical condition would be easy once the system itself was broken into. The correspondent said that given the way the TarMed application had been written, patient confidentiality could only be preserved by forcing doctors to use a separate, isolated computer for Internet browsing. The same correspondent claimed that he had also found it commonplace for doctors to leave their TarMed applications open while the PC was unattended for long periods.