How Digitally Advanced Is German Healthcare?

After three years of contact restrictions, the annual digital health conference DMEA took place again in Berlin in April 2022. The joy of meeting people face to face was palpable; so was the eagerness to find out what had changed in the past three years. This was especially true with regard to the digitization agenda of Germany’s new Federal Ministry of Health.

Continued Federal Commitment to Digitization

In his keynote speech the federal minister of health, Professor Dr Karl Lauterbach pledged to continue his predecessor’s push for the digitization of German healthcare delivery: “I see myself not only as the minister of health, but also as the minister of digitization”. A digital strategy for the German healthcare market will be set out after the parliamentary summer break, focussed on the electronic patient record (EPR): “The EPR is and remains the core task,” Dr Lauterbach said, expressing that both patients and care providers should benefit from digitization in everyday life.

For doctors, this benefit could be a search function that allows them to quickly find information in an EPR; for patients, it might be an application that links an electronic prescription with a pre-order function, so that the medication is ready for collection at a pre-selected pharmacy.

The Slow Rise of Electronic Patient Records

The EPR featured as one of the main topics discussed at DMEA. As of 1 January 2021, it became mandatory for statutory health insurances in Germany to offer EPRs; despite the legal requirement, these digital records remain in the minority — with 453,351 EPRs active currently, only 0.6% of the 73 million Germans covered by a statutory health insurer possess one. EPRs also seem unpopular with registered doctors, who have had to use them since July 2021. According to Dr Dominik Bindl, project manager at Medatixx, usage of EPRs lies at a “manageable” 3% on the part of practising physicians.

This has to do with the fact that the EPR in its current form collects little information, and is therefore of limited value. Dr Bindl thinks the slow adoption is also because of a lack of understanding about the benefits of an EPR, or for that matter any other digital solution. Carsten Fehlen, vice president of product management at CompuGroup Medical, calculated that since its introduction, an average of 958 EPRs per day have been activated; if this speed is maintained, it would take another 237 years until all insured persons would use one, assuming the next 60 federal governments stick to the EPR concept. This would be disappointing news indeed.

Evaluating Digital Maturity with the Digital Radar

The low adoption rate of EPRs among patients and clinicians is symptomatic of the sluggish digitization of German healthcare delivery. In an effort to advance the digitization of hospitals, a bill was passed in September 2020 including a federal grant of €4.3 billion for investment in health IT. Hospitals could apply for the financing of 11 types of digitization project until the end of 2021.

To evaluate this measure, participating hospitals had to agree to have their existing digital maturity measured in the last quarter of 2021 before starting their new digitization project. This would be followed up with another round of evaluation in two years’ time. The benchmarking instrument, a so-called digital radar, was developed in three months and took 64% of the existing electronic medical record adoption model (EMRAM) on board. EMRAM is a highly respected maturity model for hospitals established by the Health Information and Management Systems Society in the US. The remaining digital radar content was localized to reflect the German market and the specific digitization projects supported by the bill.

In Germany, 1,616 hospitals filled in a questionnaire with over 230 questions grouped by seven categories, accounting for 91% of all hospitals. Unlike the eight-stage  EMRAM, the digital radar is a continuous model with a total score of 100 points. The results of the benchmarking exercise showed a mean value of 33.3 throughout the participating institutions. The maximum score was 78.

Converting the results of the digital radar to the EMRAM scoring system, 69% of German hospitals are at EMRAM Stage 0, compared with 78% in the US and 96% in Australia; 27% at Stage 1; 3% at Stage 2; and 1% at Stage 3, compared with 1% in the US and 0% in Australia.

The average score from all 1,616 hospitals by category was as follows: 55% for structures and systems, 45% for resilience management and performance, 41% for organization management and data management, 39% for clinical processes, 25% for information exchange, 18% for digital health and 5% for patient participation.

For German hospitals to catch up on digitization, interoperability and structured data exchange are vital. Investments in these areas will also help hospitals address pent-up demand for clinical processes, data exchange, digital health and patient participation. All this will be facilitated by the so-called National Digital Health Agency — known in Germany as gematik — finally launching its second-generation telematic infrastructure, TI 2.0, replacing its 20-year-old precursor. The TI 2.0 platform will be resilient, incorporate zero-trust security architecture and is based on international standards for hosting healthcare applications. This should accelerate the digitization of the German healthcare sector.

Patients Need More Briefing

But discussions at DMEA emphasized that these efforts aren’t enough for speeding up the digitization process. There will also need to be clear communication of its benefits for doctors and patients: “We need to raise awareness and enthusiasm for EPRs,” noted Dr Bindl. He’s adamant about the importance of getting many more patients on board, so as to add more weight to the cause.

At DMEA, only a few patients’ voices were heard. “What would happen if we, as patients, urged the medical profession to employ the EPR, since it is ultimately us who benefit from it?”, was one question from the audience — and an important one that needs to be answered as digitization continues. For its part, DMEA contributed to the promotion of patient input.

Healthcare suppliers also play a crucial role in promoting the benefits of digitization. They’re well placed to provide strong uses for technology, including patients’ and care providers’ perspectives on what’s valuable in healthcare delivery. Teaming up with patient organizations could be a good first step in this direction.