healthcare Project Report Project Report on Telemedicine: What We Learned about the Administration and Development of a Binational Digital Infrastructure Project Norbert Hosten 1, Britta Rosenberg 1,* and Andrzej Kram 2 1 Department of Radiology, Universitätsmedizin Greifswald, Fleischmannstraße 8, 17475 Greifswald, Germany; [email protected] 2 Department of Pathology, Westpomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland; [email protected] * Correspondence: [email protected] Abstract: This article describes the development of a German–Polish cross-border telemedicine project. Funded by the European Union Interreg Program, a cooperation between several German and Polish hospitals was developed over the course of 16 years, starting in 2002. Subprojects, governance and outcomes are described, and facilitators and barriers are identified. These points are reviewed with regard to their influence on medical, technical, administrative and medico-legal realisation. Keywords: telemedicine; telediagnostic; project management; funding; IT infrastructure; cross- border multiprofessional team; European Union; Interreg 1. Introduction Citation: Hosten, N.; Rosenberg, B.; This report explores the lessons learnt from a German–Polish telemedicine network Kram, A. Project Report on funded by the European Union (EU) in Pomerania. Telemedicine: What We Learned Pomerania is a historic region on the southern shore of the Baltic sea, with a western about the Administration and Development of a Binational Digital part located in Germany and an eastern part located in Poland. The area of historic Pomera- Infrastructure Project. Healthcare 2021, nia was used to create a co-operation structure between Germany and Poland in 1995 9, 400. https://doi.org/10.3390/ (“Euroregion Pomerania”). Ten German cities and districts and 98 Polish municipalities are healthcare9040400 members of the Euroregion. The purpose of all Euroregions is the promotion of common interests. Euroregions are eligible for funding in the Interreg programs of the European Received: 1 February 2021 Union. Interreg I started in 1989. The present phase of the program, Interreg V, funded Accepted: 25 March 2021 projects until 2020. Interreg was created to promote cross-border cooperation in the EU, Published: 1 April 2021 thus diminishing the influence of national borders. The council of the Pomeranian Euroregion is located in (Polish) Szczecin, the historic Publisher’s Note: MDPI stays neutral capital of ancient Pomerania. The council is constituted in equal parts by German and with regard to jurisdictional claims in Polish members. Polish members of the Euroregion are members of a Polish association, published maps and institutional affil- while German members belong to a “Kommunalgemeinschaft”—an association according iations. to German law. Eligible projects may apply for funding from current Interreg programs. Only groups that are constituted by both German and Polish members are suitable for application. A lead partner may be either from Germany or Poland. The agency in the lead partner’s Copyright: © 2021 by the authors. country of origin will then process the request, aiming to achieve harmonisation between Licensee MDPI, Basel, Switzerland. the Polish and the German side. This article is an open access article A complete review of Interreg is beyond the scope of this paper. Perkmann [1] gives distributed under the terms and an overview of the concept and existing cross-border regions, following Schmitt-Egner’s [2] conditions of the Creative Commons definition of ‘cross-border cooperation’ as ‘cross-border interaction between neighbouring Attribution (CC BY) license (https:// regions for the preservation, governance and development of their common living space, creativecommons.org/licenses/by/ without the involvement of their central authorities” (Perkmann’s translation). 4.0/). Healthcare 2021, 9, 400. https://doi.org/10.3390/healthcare9040400 https://www.mdpi.com/journal/healthcare Healthcare 2021, 9, x 2 of 20 [2] definition of ‘cross-border cooperation’ as ‘cross-border interaction between neigh- bouring regions for the preservation, governance and development of their common liv- ing space, without the involvement of their central authorities” (Perkmann’s translation). The rationale for implementing telemedicine in the Euroregion of Pomerania was Healthcare 2021, 9, 400 2 of 21 twofold: (1) The regions on both sides of the German/Polish border are very thinly popu- lated. The German federal state of “Vorpommern” (Western Pomerania) has a population density of 69 inhabitants/squareThe rationale kilometre, for implementing while telemedicine the Polish in the Euroregion voivodeship’s of Pomerania (province) was twofold: (1) The regions on both sides of the German/Polish border are very thinly popu- “województwo zachodniopomorskie”(Voivodeslated. The German federal state of “Vorpommern”hip Western (Western Pomerani Pomerania)a) has has a population 75 inhabit- ants/square kilometredensity (mean of 69population inhabitants/square densit kilometre,y: Germany, while the 137 Polish inha voivodeship’sbitants/square (province) kilo- metre; Poland, 132 inhabitants/square“województwo zachodniopomorskie”(Voivodeship kilometre). (2) The border Western in Pomerania) the Pomerania has 75 inhabi- region tants/square kilometre (mean population density: Germany, 137 inhabitants/square kilo- between Poland andmetre; Germany Poland, 132leaves inhabitants/square several German kilometre). and (2) The Polish border inhospitals the Pomerania with region small catchment areas (Figurebetween 1). PolandTelemedicine and Germany is an leaves accepted several German means and of Polish delivering hospitals withmedical small ser- catchment areas (Figure1). Telemedicine is an accepted means of delivering medical vices to people in suchservices areas to peopleby enlarging in such areas catchment by enlarging catchmentareas [3,4]. areas [3,4]. FigureFigure 1. 1. InfluenceInfluence of of the the boundary boundary between between Germany and Germany Poland on and the catchment Poland areas on the of hospitals catchment in the cities areas of of hos- pitalsSzczecin, in the Pasewalk, cities Prenzlauof Szczecin, and Schwedt. Pasewalk, It is apparent Prenzlau that the hospitalsand Schwedt. close to the It border is apparent have small that catchment the areashospitals and that there are areas without easily accessible hospitals. close to the border have small catchment areas and that there are areas without easily accessible hospitals. Accordingly, people living in these regions may have reduced access to hospitals. To improve access to specialised medicine, a joint telemedicine project was initiated starting in 2002. With Interreg IVA funding, the most recent phase of this project was initiated Accordingly, peoplewith 11 living German in and these 11 Polish regions hospitals. may Specialities have takingreduced part were access radiology, to hospitals. pathology, To improve access to specialisedophthalmology, medicine, urology and a otorhinolaryngology joint telemedicine (ear–nose–throat project was medicine, initiated ENT) as wellstarting as radiation therapy, oncology and thoracic surgery in tumour boards. On the German side, in 2002. With Interregan extensiveIVA funding, videoconferencing the most network recent was laid phase out, which of this allowed project for the simultaneous was initiated with 11 German andtransport 11 Polish of x-ray hospitals. studies, pathology Specialities slides, endoscopy taking imagespart were and documents. radiology, pathol- ogy, ophthalmology, urology and otorhinolaryngology (ear–nose–throat medicine, ENT) as well as radiation therapy, oncology and thoracic surgery in tumour boards. On the German side, an extensive videoconferencing network was laid out, which allowed for the simultaneous transport of x-ray studies, pathology slides, endoscopy images and doc- uments. As medicine is generally organised nationally, telemedicine tends also to be national. The project described here originated in radiology and pathology, with both of them deal- ing with physician-to-physician interaction; another focus was videoconferencing. On the German side, an expensive infrastructure had to be bought and installed to support these Healthcare 2021, 9, 400 3 of 21 As medicine is generally organised nationally, telemedicine tends also to be national. The project described here originated in radiology and pathology, with both of them dealing with physician-to-physician interaction; another focus was videoconferencing. On the German side, an expensive infrastructure had to be bought and installed to support these applications. Management, facilitators and barriers for these parts of the project are described below. We report here on the lessons learned from the implementation of this Interreg IV project. 2. Materials and Methods 2.1. Previous Phases of the Project The project described here was implemented over the course of four funding periods since 2002. The first author (a university radiologist, chairman of the project’s board) has been involved from the beginning; the other two authors (in-house counsel and pathologist) have been involved since 2010. Documentation from the different project phases was used for analysis. Because public funds were used, the written documentation was comprehensive. The work presented here aims to describe facilitators and barriers and thus to provide guidance for colleagues wishing to implement