On The Brink Of A Digital Health Care Transformation: What Germany Can Learn From The United States

The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act was an undeniable success in its primary goal: deploying electronic health records (EHRs) across the US health care system, thus creating a data layer that has allowed the development of new products and services. When HITECH was passed more than a dozen years ago, few providers or hospitals in the United States had digitized their health records in a meaningful way. Fewer than 10 percent of hospitals had an EHR system. In contrast, today there are almost no acute care hospitals without one.

Yet, while HITECH was successful in moving providers and hospitals to adopt EHR systems, there remain several areas that were either not a focus of the incentive program or not fully realized. This includes issues that were known at the time HITECH passed and remain a challenge—such as interoperability. It also includes a set of issues that were less salient a decade ago but have become clear areas for policy and design improvement such as health equity, public health infrastructure, patient-centricity, provider burn-out, and payment reform.

Imagine if those involved in HITECH’s development and implementation could go back to 2009 with the aim of doing health information technology (IT) even better a second time around. What changes would they pursue, and what blind spots should they know about? Such a simple do-over is, of course, impossible—at least for the United States. But in many respects, the German health care system stands at a turning point that today looks a lot like what the US system faced in 2009.

The past few years have seen a surge in legislative advances and public policy initiatives in the German health care system that will fundamentally drive its digital transformation. Culminating in the 2019 Digital Healthcare Act, the 2020 Hospital Future Act (KHZG), and the 2021 Digital Care Modernization Act, this flurry of policy activity has provided solutions for digitizing paperwork, electronic patient records, and prescriptions. It has also established a novel pathway to reimbursement for “prescribable apps,” while dramatically increasing funding for hospital digitization projects, notably through the KHZG’s €4.3 billion (US$5.05 billion) incentive program. Germany has thus set out on a path to fundamentally modernize and digitize its health care system.

The coming years will be transformative in the German health care system as the adoption of digital technologies accelerates in domains ranging from patient-focused innovation, such as prescribable health apps, to hospital infrastructure solutions, such as computerized physician order entry systems. The combination of increased government focus, growing demand from patients, and digital maturation of the country will, in many areas, drive the kind of digital re-framing that was observed in the US in the decade following the introduction of the HITECH Act. As such, the digitization of the US health care system—with all of its successes and shortcomings—offers many lessons for Germany and other countries working to modernize and digitize their health care systems.

What follows are five of those key lessons:  

Foster Digital Equity

Digital technologies have long carried a hope of improving access to care. While there are some success stories, the US experience suggests this has been an uneven process, exacerbated by the preexisting digital divide. The COVID-19 pandemic has thrown several aspects of health inequality, such as differences in outcomes by race/ethnicity, age, and profession into stark relief. Patients who are older, have lower digital literacy, or suffer from reduced access to digital infrastructure have been disproportionately left behind by digitization in health care. Indeed disparities in simple technology infrastructure, such as access to broadband internet remain a challenge. Although racial and ethnic disparities in using the internet have narrowed over the past decade, gaps exist across ethnic and racial groups with respect to access to broadband. Similarly, while 97 percent of younger adults use the internet, less than two-thirds of adults older than age 65 do, and similar gaps exist by education and income. Such inequalities in access also disproportionately impact minorities and other traditionally disenfranchised groups, potentially exacerbating existing health disparities. For example, from 2015 to 2018, patients with limited English proficiency in California had significantly lower rates of telehealth use.

It would behoove Germany and other countries to examine drivers and correlates of health inequalities, heed lessons from the US experience, and ensure the most inclusive population possible reaps the benefits of digitization and digital tools. Indeed, it may be necessary to focus on those already receiving quantitatively and qualitatively worse care. For example, new regulations governing reimbursement decisions for digital health applications include both “facilitating access to care” and “health literacy” as criteria to support coverage by German statutory health insurers. This represents a step in the right direction. However, policy makers should place a stronger specific emphasis on inclusion, health literacy, and patient empowerment, as well as the promotion of mechanisms that tie financial incentives to these effects. Such steps can help ensure that digital tools help reduce—or at a minimum, do not exacerbate—existing health disparities.

Support Public Health Infrastructure

The United States’ large-scale digitization projects largely failed to fund public health infrastructure and its integration with other aspects of the formal health care delivery system. Because public health reporting, such as electronic case reporting, is jurisdictional, there is regional variation in policies, for example, around opt-in or opt-out requirements for immunization data to be shared at the state level. And while incentives programs—such as Promoting Interoperability, the Centers for Medicare and Medicaid Services program to encourage eligible professionals, hospitals, and critical access hospitals to adopt, implement, upgrade, and demonstrate “meaningful use” of electronic health records—have included transmission of data back to public health agencies as part of a reporting requirement, bidirectional data flow remains rare. The COVID-19 pandemic has further highlighted the importance of a well-resourced public health service and the challenges that arise when data vital to the maintenance of public health and safety cannot flow freely. Fortunately, the US Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 includes $500 million in funding for the Centers for Disease Control and Prevention to distribute for improving public health data infrastructure, part of a data modernization initiative.

As was the case in other countries, the German Public Health Service was overwhelmed during the peaks of the COVID-19 pandemic, however, newly designated funding for the Public Health Service announced in September 2020 is expected to play a large role in both staffing and digitizing the public health system. The German Electronic Reporting and Information system “DEMIS” is expected to be rolled out this year, with a particular focus on infection control and pandemic preparedness. But other aspects of public health work, such as electronic case and lab reporting also need more funding. And digitization and bidirectional data flow should be incentivized and built into digital infrastructure.

Plan For A More Inclusive, Patient-Centric Digitization Ecosystem

In the US, the HITECH Act’s public funding stream focused on physicians and hospitals, an approach that had two unintended consequences.

First, health care providers and institutions that were ineligible to benefit from the incentive program were often left behind. This included countless long-term care facilities, post-acute providers, behavioral health providers, and social service organizations—all of which play a key role in health care delivery and, indeed, represent significant contributors to health care spending. The absence of these providers in the federal incentive program has created discontinuity in digital capabilities, which has made care continuum interoperability particularly challenging. Just as it will be vital to include funding for the digitization of public health services in any large-scale digitization programs, other vital institutions and non-hospital players should be recognized and incorporated into digitization planning. A key policy priority for Germany moving forward should therefore be the passage of an equivalent of the Hospital Future Act to provide similar digitization incentives in the ambulatory care setting. As the US experience has shown, it will only be through a comprehensive approach to digitizing core health care institutions that care continuity and the true promise of interoperability will be realized.

A second unintended consequence of how HITECH funds were distributed was the resulting institution-centricity of EHRs, as opposed to patient-centricity. Rather than patients owning a single health record that could be accessed by various institutions, multiple records were created by various care providers for each patient, which then had to exchange data with each other to create complete views of patient health and medical history.

Here too, Germany has taken steps to avoid some of these shortcomings. For example, the newly-introduced Electronic Patient Record mandates interoperability and gives the patient a large degree of control over sharing their data, allowing various parties—including patients, their physicians, pharmacies, and hospitals—to access designated information in a secure manner. The roadmap for the underlying German “telematics infrastructure”—Germany’s home-grown IT infrastructure project for connecting multiple stakeholders in the health care delivery system—also aims specifically at connecting other players such as long-term care providers, non-medical therapists, health insurers, and others. However, it is still too early to determine how widespread uptake will be and whether stakeholders will feel comfortable and empowered to use this resource.

Recognize Provider Burden And Burnout

Because EHRs were adopted with such ambitious velocity in the United States, policy makers and health systems failed to fully account for the burden of data entry and interaction with new digital systems. This burden introduced incredible overhead costs in terms of both time and effort that largely fell on already overstretched medical personnel. Physicians recently reported spending 16 minutes per patient—the majority of the time allotted for a typical encounter—on documentation, while some physicians spend around 50 percent of their workday dealing with EHR-related tasks. This is partly due to the multifaceted purpose of data collection, which encompasses everything from treating individual patients, to collecting data for research, to meeting legal and billing-oriented documentation needs.

The data collection explosion has even led to the creation of new jobs, such as the medical scribe. Yet, physician professional dissatisfaction and burn-out due to EHR interaction is rampant. Germany, therefore, should continuously and thoughtfully co-develop such tools with their ultimate users—especially providers in in-patient and long-term care settings—while tying financial incentives to outcome and quality, rather than process metrics.

Move Toward Value-Based Care

In the world’s most advanced health care markets, calls are growing to move away from fee-for-service care and toward value-based care. Such a transition includes a number of structural changes involving new payment models such as increased use of bundles, thoughtfully collecting, analyzing, and sharing patient-reported outcome measures (PROMs), and re-organizing health care delivery infrastructure into integrated practice units.

Although payment models in the US have evolved since HITECH (for example, as seen in both private and public initiatives to encourage the use of bundles), EHRs are typically linked to revenue cycle management and traditional, fee-for-service billing. Consequently, some technology remains at odds with—or at least partially misaligned with—target payment models. Ideally, databases designed for the delivery of value-based care would go beyond “standard” medical data to include data on social determinants of health and other factors.

The potential mismatches between the design of digital tools and the goals of the health care system are worth keeping in mind: Software systems designed around fee-for-service health care delivery will perpetuate existing waste and shortcomings, while design that builds in opportunities for broader data collection, user-friendly personal health records, and the evidence-based deployment of personalized digital tools will support the transition to value-based care. In this respect, both the US and Germany have a long way to go. Germany, in particular, has a great opportunity to thoughtfully roll out such tools over the years ahead.

Furthermore, to take full advantage of digitized health care delivery data, systems must develop algorithms based on large and diverse population data to ensure that risk adjustment for individuals can be done on the basis of representative data from an appropriately comparable group. Algorithms need access to unprecedented amounts of anonymized data, which in turn need to be “cleaned”—not only for errors and incompleteness, but also for inherent biases. This may be particularly challenging in Europe where stricter privacy regulations provide sweeping protections for individuals on the one hand but curtail attempts to leverage information at the population level on the other. German policy makers, in particular, will have to negotiate a delicate balance between patients’ individual privacy concerns and their ability to contribute to and benefit from data sharing.

Heeding Lessons Learned

As other countries look to digitize their health care systems, it is worth examining the US experience following the passage of HITECH, especially its imperfections. In the third decade of the 21st century, policy makers will need to emphasize digital health equity, prioritize public health infrastructure, and ensure that the best interests of all stakeholders are represented.

We believe that Germany is currently in a unique position to demonstrate digital leadership in Europe while heeding lessons learned from the US experience.

Authors’ Note

J.B. Brönneke and A.D. Stern are affiliated with the Health Innovation Hub of the German Federal Ministry of Health.