Healthcare in Germany – digital first?

The world is becoming digital – internet of things, artificial intelligence, social networking, and the rapid rise of technology have fundamentally changed our private and professional life. But has the German healthcare system successfully found its way into the digital era yet?

The topic of health has never been as vital to Germans as it is today, and digital innovations offer a wide range of possibilities. Health apps, wearables, and special fitness trackers are part of our modern digital world. Founded in the 1880s, the German healthcare system – with its doctors, specialists, and facilities – is one of the best healthcare systems in the world.

According to surveys, many people would be willing to use digital applications in medical care and to provide their own data for this purpose. In the context of the healthcare reform legislation passed in 2003 (Gesundheitsreform 2003), changes with digital notations were incorporated into the German Social Code, Book V, on Statutory Health Insurance Modernization (SGB V – GKV-Modernisierungsgesetz or GMG) [1].Due to the Lipobay scandal the legislature decided to introduce the electronic health insurance card (elektronische Gesundheitskarte, eGK) [2]. An electronic medication plan stored on the eGK was supposed to prevent harmful interactions of medications in the future. This application should be usable by mid 2019. In addition, the GMG established further digital applications for the eGK in the Social Code. These include the emergency data management (Notfalldatenmanagement), an electronic patient record (elektronische Patientenakte), the electronic doctor’s letter (E-Arztbrief), and the electronic patient compartment (elektronisches Patientenfach). In 2015 the E-Health Law implemented concrete deadlines and responsibilities for the introduction of these applications. And so far, the electronic physician’s letter has found its way into the digital everyday life of physicians. The radiological telekonsil, which is based on the E-Health Law, and the video consultation are of marginal importance and only apply if a doctor has already been in contact with the patient before.

To use the electronic patient record in the future, specific technical standards will be mandatory. In accordance with legal requirements, the access to this digital file will be based on the so-called two-key-principle. Access will only be possible if the physician identifies themself with an electronic health professional card (Heilberufeausweis) and the patient does the same with their eGK at the same time. These strict requirements can only be mitigated if the patient will have given a time-limited authorization to the physician after an initial contact. However, the authentication can only be approved in the doctor’s office in the future, because it is thus far technically impossible for patients to identify themselves by means of eGK from home.

Regarding the future use of the electronic physician’s letter and medication plan, doctors are expected to equip themselves with electronic health professional cards (Heilberufeausweis), with which qualified electronic signatures – for example, on prescriptions or referrals -will be possible. It is not yet clear how patients will be able to identify themselves digitally in the future. The Social Code stipulates that the eGK must be technically capable of enabling authentication, encryption, and electronic signature. These technical requirements have not yet been implemented. In addition, the corresponding requirements of the eIDAS regulation must be complied with as of July 1, 2016.

To meet the present challenges of today’s healthcare system, digital innovations offer a wide range of solutions. The shortage of doctors in structurally weak regions, overburdened emergency rooms, and the steadily increasing number of elderly and chronically ill people are just a few examples where telemedicine and digital innovations could ensure proper medical care in the future. In Baden-Württemberg, the problem has been addressed and the ban on remote treatment (Fernbehandlungsverbot) became less tight within the framework of a pilot project [3]. At the federal level, video consultation is planned to be part of regular care in the future, even without previous doctor-patient contact.

Jens Spahn, who was sworn in as Federal Minister of Health on March 15, 2018, wants to further expand the digital scope in the Federal Ministry of Health; Minister of State Dorothee Bär is calling for more speed in digitalization [4, 5]. The coalition agreement states that the existing E-Health Law needs further refinements. Therefore, concrete measures need to be identified and developed together by the stakeholders by 2020. The implementation of the electronic health record for all insured is now planned for this legislative period. According to the agreement between CDU/CSU and SPD, new ways of approval for digital applications are to be created and interoperability will have to be established. Another goal is to integrate nursing in the telematics infrastructure, expand the coverage of telemedical services, introduce the digital recipe, and implement the digital version of the vaccination and maternity record.

So far, a widespread implementation of digitalization in the German healthcare system has not been accomplished yet. Even though, the initial approaches regarding the eGK and its applications were decent, to improve healthcare there is no alternative to increased digital cooperation. First and foremost, the coalition agreement’s plan to create new ways of approval for digital applications must be implemented rapidly. Interoperability must be established with the same priority as isolated solutions for IT applications do not lead to success. At the same time, proper security must remain the cornerstone of using and sharing sensible healthcare data. In other European countries such as Switzerland, Denmark, and the United Kingdom, telemedical services have been part of standard care for a while now; the greater degree of digital collaboration and the implementation of new technologies ensure better patient care. The Bertelsmann Stiftung is planning an international comparative study on the digitalization concepts of 17 different healthcare systems [6]. The results could help Germany learn from the successful concepts of other countries and thus help to meet the challenges of the healthcare sector with digital innovations. Germany has an excellent healthcare system. But when it comes to the elevation of the healthcare sector to a new digital level, Germany does not belong to the top countries in Europe. However, with the effort of all stakeholders, Germany can seize the opportunities provided by new technologies in the future.