Not all Europeans are created as equals

Europe is divided once again. The digital patient is a reality in some countries, while in many others, the paper patient continues to dominate. Insights has travelled to the extremes. We visited Sweden to learn how it feels for a patient to become ever more digital. And we went to the other side of the wall, to Germany, where a fully digital healthcare system is still a distant fantasy. Or isn’t it? In fact, 2018 could bring some light at the end of the tunnel.

Grätzel von Grätz

When you ask Swedes about how much of their healthcare system is digitised these days, there is a chance that they don’t quite understand what you mean. By most standards, Swedish healthcare is in fact fully digitised: “Broadly speaking, electronic health records are used by almost 100% of Swedish hospitals and primary care physicians,” says Karina Tellinger from the Swedish Association of Local Authorities and Regions (SALAR). 

Sweden: National and regional digital services come together

According to Karina, around 98% of all prescriptions in Sweden are ePrescriptions now: “All doctors can communicate electronic prescriptions to every single pharmacy in the country. Pharmacists will in fact not be allowed to run a pharmacy anymore if they cannot handle electronic prescriptions.” Notifications on sick-leaves, too, are more or less comprehensively digitised.

But digital health information exchange is not all the Swedish eHealth infrastructure is about. Patients, too, can interact with the healthcare system digitally, and increasingly so. “We have three different types of services in the Swedish healthcare system,” explains Karina. On the national level, there is the national healthcare portal that was created in 1999 already. It is called, and it is currently accessed about 10 times per citizen per year. The portal offers guidance on different kinds of symptoms and diseases. It features a database of doctors and hospitals and offers the possibility to ask anonymous questions to healthcare professionals. 

The second service for patients is a national phone number – again the 1177 – that was introduced in 2006 and that offers healthcare advice by phone. Third, there are various online tools at the level of the individual Swedish regions. “The details depend on the region, but in all regions there are many different personalised services available,” says Karina Tellinger. 

Giving citizens access to EHR data is mandatory

Patients can, for example, book an appointment electronically, which is done around 500,000 times per year at the moment. Chronically ill patients can ask for prescription renewals. And each citizen can access all information relating to themselves that is stored in the regional electronic health record. “Patients see more or less the same information as the doctor. It is mandatory that the county council gives digital access to the electronic health records to every citizen above 18.”

Representatives can also be nominated who can manage the digital data on behalf of the patient. “In general, there is the rule that specific information can be hidden without consent of healthcare providers. But this varies a little from region to region. In some regions, there is a delay of a couple of days before, for example, laboratory data becomes visible for the patient.”

In summary, the Swedish healthcare system is pretty advanced in digitising communication between healthcare providers and providing digital patient access and digital patient engagement tools. There are limits, though, that have to be addressed now. In recent years, an ever increasing number of Swedes have been using online video consultations to meet their doctors. Many teleconsultations are already reimbursed by the Swedish healthcare system, so the trend looks set to continue. But this “virtual” healthcare system remains, for the moment, utterly disconnected from the rest of Swedish healthcare.

This is why Sweden is now embarking on a major healthcare IT modernisation path. (See interview with Daniel Forslund.) 

Germany: The analogue citizen remains the rule

In Germany, the situation is fundamentally different. The biggest European economy is lagging way behind other European countries when it comes to digitising healthcare. It’s not that nobody talks about it. In Berlin, there are events on healthcare digitisation more or less every week. But the German healthcare system has a very unusual structure that makes a comprehensive digitisation a daunting task. Doctors and health insurance companies are extremely powerful. The national Ministry of Health can only set the framework and hope that the system eventually complies. 

To complicate matters further, the federal states, too, have a say. They are responsible for privacy regulations. They co-finance hospitals and indeed run many of them. All in all, the only promising approach to healthcare digitisation within the given framework in Germany is a highly consensus-based one, i.e. trying to reach mutual agreements between health insurance providers, doctors and data protection agencies on standards, technologies and applications. 

What are the chances of achieving digital healthcare goals? The current reality is that there is not a single ePrescription being issued in German healthcare. There is no such thing as comprehensive electronic health or patient records that can be accessed online by citizens anywhere. What does exist, at least partially, is digital communication of lab results and referral letters. This is based on an infrastructure called SNK that was built jointly by the Kassenärztliche Vereinigungen (KVs), the regional representative bodies of doctors in private practice. What also, again partially, exists is digital communication between co-operating hospitals in certain regions. And there are some health insurance providers now that are building electronic health records and try to co-operate with hospitals and with KVs in order to get relevant data in.

National infrastructure reloaded

All this won’t sound impressive at all to ears from Sweden, let alone Estonia, Denmark, Spain or indeed the UK. But there is some light at the end of the German tunnel. The German national healthcare IT infrastructure project that has been ongoing, at varying speeds, for ten years now and that up until now – despite having cost several billion Euros – has provided zero results, looks set to accelerate somewhat. The plan is that several thousand doctors will be connected to a (consensus-based) national infrastructure in 2018. 

The responsible body, the Gematik, run jointly by doctors and health insurers, has recently certified the first highly secure VPN box, called ‘Konnektor’, a product of CompuGroup, and will likely certify two or three more in 2018, among them one by RISE, the company that produces the VPN boxes for the Austrian ELGA-network. Should everything go as planned, Germany should have a healthcare system-wide, smartcard-based and thus somewhat clumsy digital communication infrastructure within two years or so.

Doctors can now file for pilot projects with telephone or video or online consultations of unknown patients. Two of these projects will start by March 2018, and they have the potential to change the way ambulatory healthcare is provisioned in Germany.

The big question is how fast doctors and health insurance companies will now agree on real patient applications, and whether the certification requirements of Gematik will be manageable enough to convince innovative start-ups to develop and certify applications based on Gematik-specifications. The fact that Germany continues to have only an interim government at the moment isn’t necessarily a problem for the national infrastructure project. This, at least, is an advantage of having a system that acts mostly independent from the Ministry of Health.

Video services on the horizon

There is one other development in German healthcare at the moment that might, in the long run, do much more in terms of digitising the German patient than every infrastructure project. The federal and national chambers of doctors are in the process of redefining what is allowed and not allowed for doctors to do online. At the moment, German doctors are allowed to use, for example, video-consultations to see and treat patients whom they already know and who come physically to their office regularly. What is not allowed is to diagnose and treat an unknown patient by phone or online.

This means that a model like the Medgate-model in Switzerland, in which patients with minor medical problems can initiate a tele-consultation and get their prescription and their sick-leave notification without seeing a doctor physically, is not possible under German law, because the doctors’ chambers don’t consider this compatible with proper medical care. The recent boom of video-consultations in Sweden, too, could not have happened in Germany, for similar reasons.

Major revolution ahead

But this is about to change, after years, if not decades of discussions. The regional chamber of doctors in Baden-Württemberg has recently rewritten its code of conduct. Doctors can now file for pilot projects with telephone or video or online consultations of unknown patients. Two of these projects will start by March 2018, and they have the potential to change the way ambulatory healthcare is provisioned in Germany.

Even more encouraging is that the national chamber of doctors is also planning to rewrite its code of conduct. This national code is used as a blueprint by most federal chambers. The responsible body, the Bundesärztekammer, has announced that it plans not only to allow teleconsultations of unknown patients, but also that it doesn’t want a specific approval process for these kinds of offers. Should this be adopted by the parliament of German doctors in May 2018, it wouldn’t be a step but a revolution.

Related content:

Moving towards a holistic healthcare ecosystem  

Philipp Grätzel von Grätz

(Germany) specialises in medicine, health policy and, in particular, eHealth and information technology in healthcare. He is one of Europe’s leading journalists in the field and author of the German book Connected Health.

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