German e-health offerings expand, but adoption remains uneven

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The e-Health Monitor 2022 is McKinsey’s third annual review of the progress of digitization in the German healthcare system. It encompasses the perspectives of academia, hospitals, outpatient physicians, telemedicine providers, pharmacies, payers, public-sector players, and patients. It includes original McKinsey research, cited sources, and perspectives from 16 renowned academics and leaders of major healthcare institutions and digital health companies. As in previous years, the report has two main parts. The first part analyzes the overall state of German healthcare digitization, using 30 indicators to assess e-health progress along several dimensions: regulatory framework, digital infrastructure, and e-health demand and supply, usage, and benefits. The second part addresses this year’s focus topic: the electronic patient record or, as known in Germany, ePA (elektronische Patientenakte).

Part 1: The state of German healthcare digitization

A McKinsey analysis has estimated the value of digital health solutions for the German health system at an annual value potential of €42 billion, mainly on the basis of productivity gains and demand reduction. This figure represents approximately 12 percent of Germany’s overall annual healthcare expenditure. So far, only €1.4 billion, or just over 3 percent, of this value has been realized.1

Regulatory framework

In the past two years, four new laws and regulations have expanded the regulatory framework for e-health in Germany. One law includes a category for digital-care applications, called DiPA2 (digitale Pflegeanwendungen), which will soon be rolled out. In addition, legislative and regulatory activity is aimed at strengthening the interoperability, governance, and infrastructure of the health information exchange (Telematikinfrastruktur, or telematics infrastructure) and associated use cases such as electronic patient records and e-prescriptions.

In its December 2021 coalition agreement, the new federal government declared the digital transformation of Germany’s healthcare system to be a priority and announced the development of a national e-health strategy. Priorities include realignment of the telematics infrastructure and continued national implementation of electronic patient records and e-prescriptions.

Reimbursement for digital healthcare also has evolved, with the introduction of remote-patient-monitoring reimbursement codes for heart failure and a rollback of telemedicine regulations. As of April 2022, reimbursement for teleconsultations has been capped at 30 percent of total consultations for a given physician practice (earlier in the COVID-19 pandemic, physicians and psychotherapists could get reimbursed for an unlimited number of teleconsultations).3

Digital infrastructure: Uptake and maturity

Outpatient physicians. Outpatient doctors continue to adopt the national telematics infrastructure: by the second quarter of 2022, 96 percent of outpatient practitioners were linked to the telematics infrastructure, up from 90 percent in 2020. However, half of doctors encounter technical issues on at least a weekly basis, up from 36 percent in 2020.4 Overall, frustration with the digitization process has grown. A large share of outpatient physicians are dissatisfied with digitization’s unfavorable cost–benefit ratio (cited by 65 percent of GP respondents in 2021, compared with 56 percent in 2020) and the need for outsize efforts to digitize clinics (also cited by 65 percent of GPs, up from 58 percent).5

Pharmacies. As of the second quarter of 2022, 99 percent of pharmacies were connected to the telematics infrastructure, a significant increase from 75 percent in 2021.6 However, 87 percent of pharmacists worry that the e-prescription program will prompt greater competition from online and mail-order pharmacies.7

Hospitals. Hospitals are nearly fully connected to the telematics infrastructure; those that are not face financial penalties. In a digital maturity assessment of hospitals conducted by DigitalRadar, a consortium hired by the German Ministry of Health, hospitals scored an average of 33 out of a possible 100 points, with none exceeding 64 points. They scored best in the categories “structure and systems” and “resilience and performance management”; scores on “information exchange,” “telehealth,” and “patient participation” were lower. A comparison of German hospitals against the international Healthcare Information and Management Systems Society’s electronic medical record adoption model (EMRAM) shows that German hospitals’ level of digital maturity is similar to that of peers in the United States, Australia, and Canada’s most populous province, Ontario. Most hospitals in those countries received an EMRAM score of 0 out of 7, while 27 percent of German hospitals scored 1; Ontario had the second-highest percentage of hospitals that scored 1, at 7 percent.8 Nevertheless, while digital data exchange between German hospitals and outpatient physicians has tripled, from 4 percent in 2020 to 12 percent in 2021, much room for improvement remains.

Digital health applications: Supply and demand

The COVID-19 pandemic has accelerated digital health solutions in Germany. On the supply side, 61 percent of outpatient physicians had digital offerings for patients in 2021—primarily telemedicine (37 percent) and online booking (21 percent)—a slight increase from 59 percent overall in 2020.9 Those offerings led to 3.5 million teleconsultations in 2021, an increase of 29 percent from the 2.7 million in 2020.10 It remains unclear how teleconsultation volume will evolve, particularly given the aforementioned rollback of reimbursement for it. In the meantime, 47 percent of physician and psychotherapy outpatient offices have scaled back their telemedicine offerings, citing low patient demand (49 percent of outpatient offices), fewer COVID-19 restrictions (40 percent), and limited applicability of digital solutions to the treated indications (31 percent).11

Statutory health insurance organizations have continued to expand their digital offerings. As of 2022, all of the top 20 statutory insurers offer stand-alone apps, online claims submissions, and well-being programs (for nutrition, exercise, and smoking cessation, for example). The biggest increase was in informational medical video chats, which 11 of the top 20 statutory insurers offered in 2021, compared with 16 in 2022.12

Acceptance by patients

German citizens and patients are most interested in the convenience and flexibility of digital health solutions. In a 2022 survey by Doctolib, best known for its online appointment-booking platform, 66 percent of patients indicated their interest in using online booking, 58 percent e-prescriptions, and 55 percent digital transmission of diagnostic results. Teleconsultation ranked lower among patient preferences: 24 percent of respondents selected it, despite its rise in adoption during the pandemic.13

Actual usage of digital health solutions, not just preferences for them, was also investigated. According to a 2021 EPatient Analytics survey, online well-being programs are used most widely: 31 percent of surveyed individuals took part in them as of the fourth quarter of 2021 (more than double 2019’s reported usage). Twenty-nine percent of respondents have used online booking tools and 13 percent online consultations, while 14 percent use apps to accompany a medical device, 13 percent use them for medication adherence, and 8 percent to navigate a particular clinical intervention. In 42 percent (for medical device apps) and 46 percent (for adherence apps) of cases, users found these solutions on their own; only 6 percent say a healthcare professional recommended the app.14

According to McKinsey analysis, only 7 percent of patients—up one percentage point from 2021—with any of eight chronic conditions (hypertension, chronic back pain, migraine, tinnitus, type 2 diabetes, obesity, depression, and multiple sclerosis) use an indication-specific app. As in the previous year, multiple sclerosis is the chronic disease with the highest proportion of app users: 66 percent, up from 56 percent in 2021.

DiGA (digitale Gesundheitsanwendungen, or digital health applications)—prescription apps that have gone through the formal nationwide regulatory and reimbursement process set by Germany’s Federal Institute for Drugs and Medical Devices (BfArM)—have seen continued growth. Of 52 apps that applied for inclusion on the DiGA list from August 2021 to July 2022, seven have been listed provisionally and seven permanently. Of the 33 DiGA listed as of July 2022, 14 address mental health, five hormone and metabolism conditions, and four musculoskeletal conditions. Exhibit 1 categorizes the DiGA by stage of the approval funnel.

From August 2021 to mid-July 2022, there were 52 new prescription digital health applications, with the number of listed prescription applications rising from 19 to 33.

Interestingly, according to the insurer Techniker Krankenkasse (TK), only 4 percent of physicians had prescribed a DiGA as of early 2022. By mid-year 2022, DiGA prescriptions had risen to 62,000, compared with approximately 45,000 in all of 2021.15 In a conservative-growth scenario, with DiGA numbers in the second half of 2022 similar to those in the first half, an estimated 125,000 DiGA would be prescribed in 2022. Given an average price of €396 for permanently listed and €493 for conditionally listed DiGA, the corresponding DiGA market size in 2022 would be about €57 million. Of course, if growth in DiGA prescriptions continues to accelerate, the market could exceed €60 million by the end of 2022.16

So far, patients seem satisfied with DiGA: 63 percent of those who have previously used a DiGA report a positive clinical outcome, and 86 percent would use another DiGA to treat or manage a future medical condition.17

E-health research

After several years of strong growth in e-health research publications, 2022 has seen a slight decline, not only in Germany but also in the United Kingdom, Italy, France, and Spain. The United Kingdom continues to lead e-health research, with 221 publications in 2021, followed by Germany, with 99 publications in the same year. The largest proportion of German research on e-health in 2021 focused on management and remote monitoring of chronic diseases, particularly cardiovascular diseases.

Among 204 e-health studies obtained from for a McKinsey analysis, 163 showed the benefits of e-health solutions. Of the 163 studies, 77 percent documented that e-health solutions improved health outcomes, 20 percent showed they saved time, and 3 percent identified cost savings.

Part 2: Focus topic 2022—Electronic patient records

The telematics health information exchange infrastructure, the backbone of the German digital healthcare system, is managed by the German e-health agency Gematik. The objectives are to safely enable the rapid exchange of information among healthcare stakeholders—including patients, clinics, hospitals, pharmacies, and payers—and to provide a secure platform for core e-health use cases such as e-prescriptions, electronic patient records, electronic medication plans, and organ-donor registries.

This chapter of the e-Health Monitor 2022 examines the progress of the use cases and how to achieve adoption at scale. Exhibit 2 highlights the growth in some core use cases.

Telematics infrastructure use cases have grown steadily since 2021.

Here is a status summary for the main national e-health use cases:

Electronic patient records (ePA in Germany). Since January 2021, all statutorily insured citizens in Germany can opt in to the electronic patient record program of their health insurer. The current version (2.0) of ePA primarily allows for managing documents such as vaccination records and children’s examination booklets. Version 2.5, which should be released in 2023, is expected to enable further integration of e-prescription records, laboratory diagnostic results, and electronic certificates of incapacity to work that patients present to their employers; to allow research institutes to use anonymized data for academic studies.18 Uptake has been limited—ePAs have been downloaded by only about 500,000 citizens, or 0.7 percent of those with statutory health insurance. Also, these citizens don’t often use their ePA: given that only 135,000 documents had been uploaded by September 2021, many ePAs remain “empty.”19

E-prescriptions. With about 760 million annual prescriptions overall, Germany could benefit greatly from e-prescriptions.20 Despite the original plan for a nationwide e-prescription launch in 2022, a sequential rollout was announced in December 2021. Two pilot regions (SchleswigHolstein and Westfalen-Lippe) were supposed to begin issuing e-prescriptions in September 2022. However, in August 2022, the Association of Statutory Health Insurance Physicians in Schleswig-Holstein announced that physicians were withdrawing from the pilot program because of data-protection concerns. In November 2022, Westfalen-Lippe also announced its withdrawal, citing similar concerns and leaving the outlook for a nationwide rollout uncertain.21 Despite the setbacks, introducing e-prescriptions nationwide remains a goal for 2023, according to Gematik.22

Digital health communication tools. Two digital health communication tools are being deployed in Germany: The first, Communication in Medicine (KIM)—which enables secure email exchange among payers, providers, and pharmacies—handled more than 13.7 million emails from November 2021 to June 2022; since January 2022, physicians must use KIM to send electronic certificates of incapacity to work to the statutory health insurer.23 The second tool is TIM (Telematic Infrastructure Messenger), which pharmacies, providers, and insured individuals use for instant messaging. TIM launched in the summer of 2022, and insured citizens should be able to use it through their ePA app starting in 2023.

Electronic medication plan (EMP) and organ-donor registry. The EMP contains a record of all medications prescribed to a patient, who can save it to their electronic health card on an opt-in basis. Going forward, EMPs are expected to be integrated into the ePA and, thus, linked to the telematics infrastructure, thereby permitting patients to use EMPs independently of their electronic health cards. The national organ-donor registry, currently under development, also will be linked to the ePA system.

Boosting ePA adoption means increasing the number of users, raising the level of activity, and improving the value of these use cases. In countries such as Denmark, Sweden, and Israel, factors associated with success include systematic user inclusion (for example, through default opt-outs rather than opt-ins), greater interoperability, design, and implementation of integrated customer journeys, involvement of providers and pharmacists in the design and distribution of solutions, financial incentives, and the implementation of digital tools that truly add value over that of their analog counterparts.

For the digitization of Germany’s healthcare system to succeed, all stakeholders must become more willing and able to use and transmit data. The growth of individual solutions—from teleconsultation and online appointment bookings—show that broad adoption is possible.

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