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The German E-Health Card: Key Implementation Issues

By IGI Global on Oct 15, 2010

IGI Global would like to thank Mr. Manuel Zwicker, Professor Juergen Seitz, Mr. Ralf Zimmermann and Professor Nilmini Wickramasinghe for contributing this guest editorial post. For comments and discussion you may email Mr. Zwicker at Manuel.Zwicker@gmx.de, Professor Seitz at seitz@dhbw-heidenheim.de, Mr. Zimmermann at ralf.zimmermann@emds-ag.de, and Professor Wickramasinghe at nilmini.wickramasinghe@rmit.edu.au.

Introduction

The implementation of the e-health card (eHC) will totally change the current healthcare system in Germany. New functions will be available and the focus will move more to the electronic-based view. These new functions include electronic prescriptions, electronic patient records and the emergency data of the individual or enrollee in case of an emergency.

In spite of these new functions though, this does not mean that there are only advantages. There are also disadvantages.

Healthcare in Germany

Healthcare is a growing industry over the last 40 years. Between 1970 and 1997 the percentage of Gross Domestic Product (GDP) spent on healthcare by 29 members of the Organization for Economic Cooperation and Development (OECD) rose from 5.0% to 8.1%. (Huber 1999, p. 3)

Since 2000, total spending on healthcare in these countries has been rising faster than economic growth, which results in an average ratio of health spending to GDP of 9.0% in 2008. Challenges like the technological change, longer life expectation, and population aging will push health spending up in the future. Therefore, the growing health spending creates a cost pressure for several countries such as Germany. (OECD 2010a)

Hence, reducing these expenditures as well as offering effective and efficient quality healthcare treatment is becoming a priority globally. Technology and automation have the potential to reduce these costs. (Ghani et al. 2010, pp. 113-130)

In 2008, Germany had a total expenditure on health (% GDP) of 10.5%, which was 1.5% higher than the average ratio of the OECD countries. The US spent the most with 16.0%, while France (11.2%) and Switzerland (10.7%) also had a higher value than Germany. Concurrently, Germany's total expenditure on health per capita was $3,737 (US$), whereas the OECD countries spent in average $3,060 per capita, and the US spent the most again with $7,538. (OECD 2010b, p. 1)

The healthcare actors in Germany are divided into enrollees, service providers (medical doctors, pharmacists, hospitals), and cost units (health insurance companies). Germany has around 82.14 million inhabitants. Around 70.23 million people have public health insurance, and around 8.62 million people have private health insurance. Furthermore, Germany has 319,697 medical doctors, 2,087 hospitals and 21,602 pharmacies, where 48,030 pharmacists work. (BMG 2009, pp. 9-133)

Hence, all these healthcare actors will be affected by the new German eHC.

The Concept of the E-Health Card

With the implementation of the e-health card (eHC), people in Germany can benefit from several new functions. Generally, the functions of the e-health card are divided into two category groups. Firstly, there is the area of administrative functions, which are compulsory for the card owners. Secondly, there is the area of medical functions, which are optional for the card holders. Both areas consist of two steps, which can be seen in the following figure 1. (CW Haarfeld 2010)

Fig. 1: Implementation steps of the eHC (adapted from CW Haarfeld 2010)

The implementation of the e-health card in Germany begins with the implementation of the administrative functions. Therefore, in the first step of the implementation of the e-health card, information about the insurance agreement and the necessity of additional payments will be stored. The data will be stored on the e-health card and can be updated, for example, during every consultation of a medical doctor through an online process. In addition, this first step includes data about the care provider and the personal information about the enrollee, as well as the lifelong valid insurance number. Furthermore, private insurance companies can also add information about the scope of services, which a private enrollee can utilize during a stay in hospital. (CW Haarfeld 2010)

Moreover, the first step of the administrative area includes an insurance-coverage for the enrollee within the European Union. But the requirement here is that the appropriate countries have a social agreement among each other. The back side of the e-health card is ideal as identity card for this European Health Insurance Card (EHIC). (European Commission 2010)

The new e-health cards are equipped with this EHIC independent from the insurance company. Therefore, the "old" E-111-Formulars, which were used in the past during a stay abroad in another European country, are not longer required. (EU-Info Deutschland 2010) However, these EHICs are only applicable for enrollees of a public health insurance company, because enrollees of a private health insurance company usually have insurance-protection worldwide. (Verband der privaten Krankenversicherung e.V. 2010, p. 10)

The second step of the administrative functions includes the electronic prescription (e-prescription), which is also compulsory for all involved actors of the German healthcare system. Based on this concept, it is possible to remove the nearly 600-700 million paper-based prescriptions and to process these transactions electronically. The process looks like this: At first, the doctor has to look on the insurance data of the patient. Therefore, the doctor can use the eHC of the patient and can read all the essential data with a special reading device. When the patient needs some medicine, the doctor can store the data of the decreed medicine in electronic form (e-prescription) on a special server where a pharmacist only has access when the e-health card is shown to him. The necessary signature of the doctor will be generated electronically with the aid of an electronic health professional card (HPC). (Die gesetzlichen Krankenkassen 2007, pp. 1-2)

When a patient wants to redeem the electronic prescription in a pharmacy then the procedure goes in the reverse direction. Firstly, the validity of the doctor's signature will be checked. After the following presentation of the medicine through a pharmacist or another authorized staff member, the electronic prescription will become invalid and the data will be transmitted to the pharmacy's data center. (Die gesetzlichen Krankenkassen 2007, p. 2)

With the medical functions in step 3, the voluntary part begins for the enrollees and their e-health card. This means nothing more than that the enrollees can decide on their own if they want to use these additional functions or not. The main focus here is on the storage of personal health data from the enrollees. Examples are the documentation of medicine which an enrollee has used or the storage of emergency data for the enrollee in case of emergency. Through the medicine documentation it is possible to avoid interdependencies between the individual drugs. (gematik 2010a) Furthermore, the emergency data should help the emergency doctor to medicate purposefully and effectively. For example, this could help the doctor to take allergies or chronic illness into consideration for the patient's therapy. (BMG 2010a, pp. 1-4)

The fourth and final step includes the electronic health record (EHR), among other things. With this EHR it is possible to have access to the all of patient's data. Thereby it is not important if the data is stored in one place or in different places, because the patient's data can be accepted, processed, and attended centrally. (GVG 2004, p. 9)

Advantages and Disadvantages of the E-Health Card

The implementation of the eHC implicates advantages and also disadvantages. At this point, it is essential to differentiate between the enrollees, service providers (medical doctors and pharmacists), and cost units (health insurance companies).

The eHC will help enrollees get a higher quality of therapy. The reason for this is that the eHC makes data of patients available faster, which means that redundant examinations and administration of inappropriate drugs can be avoided. (Medline 2010a)

Another advantage for the enrollees is that with the storage of the health data they will receive a better overview of their health status and thus their personal responsibility will be starched. Moreover, the enrollees have great concern about their data and can therefore decide on their own which medical data should be stored and which not. Based on the data protection and data security, the enrollees can decide which doctors have access. (Medline 2010a) In addition, the last fifty data accesses will be logged. (gematik 2010b, p. 17)

The service providers have the advantage that they can get a fast and extensive overview of the patient's status of health owing to the eHC. Through the documentation of the medical data, redundant examinations can be avoided. Additionally, in case of an emergency the doctor can take all former examinations from other service providers into account during his diagnosis. (Medline 2010b)

Furthermore, the service providers have the advantage that they can save time thanks to their optimized workflow. This time can be added to the patient's examination and therapy. (Medline 2010b)

For the cost units, which are the health insurance companies, the eHC also brings a lot of advantages. For example, due to the reduction of redundant examinations, the health insurance companies can realize cost savings. The documentation of the medicine avoid on the one hand that the patient will be examined with inadequate medicine and on the other hand this fact also results in cost savings for the health insurance companies. (Medline 2010c) As mentioned before, service providers write around 600-700 million prescriptions annually. In Germany, approximately 90% of all enrollees have public health insurance, which will exclusively use the electronic prescription. (Monetos 2010) In addition, some of the 8.6 million private enrollees will also use this e-prescription. (PKV 2009) Based on these facts, approximately 500 million Euros can be saved every year. (Scheer 2009, p. 5)

Finally, the fact that the eHC is definitely assignable to the card holder is also an advantage for the health insurance companies. This is an advantage because unauthorized usage of medical services through a third party can be avoided. (gematik 2010c)

The disadvantages, which are occurring through the implementation of the e-health card in Germany, can be summarized under the point of very high implementation costs of approximately 1.7 billion Euros and 150 million Euros running costs every year. (Scheer 2009, p. 5)

Conclusion

This article has shown that with the implementation of the e-health card, the healthcare sector and all its actors will be confronted with a lot of new functions, which are partly compulsory and partly voluntary. All these functions will lead to a more connected healthcare system, which brings a lot of advantages, but also disadvantages.

Because patients' data is very sensitive, data protection and data security play an important role. Therefore in closing, it is important to stress that the whole concept needs to be defined, designed, developed and tested very carefully, which will be a big challenge for all healthcare actors in Germany over the coming years.

References

BMG – Bundesministerium für Gesundheit (2009). Daten des Gesundheitswesens 2009. Retrieved September 16th, 2010 from www.bmg.bund.de/SharedDocs/Publikationen/DE/Daten-des-Gesundheitswesens2009,templateId=raw,property=publicationFile.pdf/Daten-des-Gesundheitswesens2009.pdf.

BMG – Bundesministerium für Gesundheit (2010). Informationen zum Thema Notfalldaten. Retrieved September 16th, 2010 from www.bmg.bund.de/cln_160/SharedDocs/Downloads/DE/Standardartikel/E/Glossar-Elektronische-Gesundheitskarte/Notfalldaten,templateId=raw,property=publicationFile.pdf/Notfalldaten.pdf.

CW Haarfeld (2010). Stufenweise Einführung der Funktionen der elektronischen Gesundheitskarte. Retrieved September 14th, 2010 from www.cw-haarfeld.de/egk/suche/showpage.php?page=stufen&sesid=EKG7-1213381815297077.

Die gesetzlichen Krankenkassen (2007). Das elektronische Rezept. Retrieved September 15th, 2010 from www.gkv.info/gkv/fileadmin/user_upload/Projekte/Telematik_im_Gesundheitswesen/2.1.7
_das_elektronische_rezept.pdf.

EU-Info Deutschland (2010). Die europäische Krankenversicherungskarte. Retrieved September 14th, 2010 from www.eu-info.de/sozialversicherung-eu/5873/7355/.

European Commission (2010). The European Health Insurance Card. Retrieved September 14th, 2010 from http://ec.europa.eu/social/main.jsp?catId=559.

gematik – Gesellschaft für Telematikanwendungen der Gesundheitskarte mbH (2010a). Anwendungen der eGK. Retrieved September 14th, 2010 from www.gematik.de/cms/de/egk_2/anwendungen/anwendungen_1.jsp.

gematik – Gesellschaft für Telematikanwendungen der Gesundheitskarte mbH (2010b). Whitepaper Sicherheit. Retrieved September 16th, 2010 from https://www.gematik.de/cms/media/dokumente/pressematerialien/dokumente_1/gematik_
whitepaper_sicherheit.pdf.

gematik – Gesellschaft für Telematikanwendungen der Gesundheitskarte mbH (2010c). Viel mehr als eine neue Krankenversichertenkarte. Retrieved September 16th, 2010 from https://www.gematik.de/cms/de/egk_2/egk_3/egk_2.jsp.

Ghani, M., Bali, R., Naguib, R., Marshall, I., & Wickramasinghe, N. (2010). Critical issues for implementing a Lifetime Health Record in the Malaysian Public Health System. International Journal of Healthcare Technology and Management (IJHTM) 11 (1/2), 113-130.

GVG – Gesellschaft für Versicherungswissenschaft und –gestaltung (2004). Managementpaper Elektronische Patientenakte. Retrieved September 16th, 2010 from http://ehealth.gvg-koeln.de//cms/medium/676/MP_ePa_050124.pdf.

Huber, M. (1999). Health Expenditure Trends in OECD Countries 1970-1997. Health Care Financing Review 19.

Medline (2010a). Vorteile der eGK für Patienten. Retrieved September 15th, 2010 from https://www.medline-online.com/die-gesundheitskarte/vorteile-patient.html.

Medline (2010b). Vorteile der eGK für Ärzte. Retrieved September 15th, 2010 from https://www.medline-online.com/die-gesundheitskarte/vorteile-praxis.html.

Medline (2010c). Überblick eGK. Retrieved September 15th, 2010 from https://www.medline-online.com/die-gesundheitskarte/ueberblick.html.

Monetos – Independent Information and Research on the European Private Financial Sector (2010). Gesetzliche Krankenversicherung. Retrieved September 15th, 2010 from www.monetos.de/versicherung/gesetzliche-krankenversicherung/.

OECD (2010a). Growing health spending puts pressure on government budgets. Retrieved September 16th, 2010 from www.oecd.org/document/11/0,3343,en_2649_34631_45549771_1_1_1_37407,00.html.

OECD (2010b). OECD-Gesundheitsdaten 2010: Deutschland im Vergleich. Retrieved September 14th, 2010 from www.oecd.org/dataoecd/15/1/39001235.pdf.

PKV – Private Krankenversicherungen.de (2009). Zahl der privat Versicherten erreicht neuen Höchststand. Retrieved September 16th, 2010 from www.privatekrankenversicherungen.de/news/00082_Zahl-der-privat-Versicherten-erreicht-neuen-Hoechststand.php.

Scheer, A.-W. (2009). Wie stehen die Deutschen zur elektronischen Gesundheitskarte? Retrieved September 15th, 2010 from h ttp://www.bitkom.org/files/documents/BITKOM-Praesentation_Gesundheitskarte_22_10_2009.pdf.

Verband der privaten Krankenversicherung e.V. (2010). Die elektronische Gesundheitskarte in der privaten Krankenversicherung. Retrieved September 15th, 2010 from www.private-gesundheitskarte.de/broschueren_materialien/pkv_broschuere_zur_einfuehrung_der_egk.pdf.

Manuel Zwicker (MBA, Diploma in Business Information Systems) is a PhD student at Royal Melbourne Institute of Technology (RMIT University), Australia. His research is in the area of business information systems, especially in the area of e-health. He received his MBA from ESB Business School, Reutlingen, Germany and his diploma from Heidenheim University of Cooperative Education, Germany (today Baden-Wuerttemberg Cooperative State University Heidenheim, Germany). During his studies, he decided to participate in different exchange programs with universities in USA, Poland, Denmark and Mexico. Furthermore, he worked in a German financial institute for several years.

Professor Juergen Seitz (PhD, Dipl. oec, Dipl.-Betriebswirt) received his PhD from Viadrina University Frankfurt (Oder), Germany. He researches and teaches within the business information systems domain including e-business, finance and banking, as well as economical impacts of IT. Prof. Seitz is member of the executive council of the Information Management Resources Association. He is associate editor and member of review boards of several journals. He is professor for information systems and head of the business information systems department at Baden-Wuerttemberg Cooperative State University Heidenheim, Germany, the former University of Cooperative Education.

Ralf Zimmermann (Diploma in Business Information Systems) is Executive Senior Consultant for electronic health, electronic and mobile business at EMDS AG in Stuttgart, Germany. In addition, he is Chief Information Officer and Training Director of this corporation, which is a consulting company for business process optimization by using innovative information technologies with focus on banking, manufacturing and healthcare industries. He has strong expertise in managing high complex and international IT projects and expert knowledge in software development, system conception, project, IT and business process management. Moreover, Ralf Zimmermann gives lectures in business information systems at Baden-Wuerttemberg Cooperative State University Stuttgart and Heidenheim, Germany, and is member of numerous examination boards.

Professor Nilmini Wickramasinghe received her PhD from Case Western Reserve University, USA. She researches and teaches within the information systems domain. Her research work focuses primarily on developing suitable models, strategies and techniques grounded in various management disciplines to facilitate more effective design, development and implementation of IS/IT solutions to effect superior, patient centric healthcare delivery. She has collaborated with leading scholars at various premier healthcare organizations throughout US and Europe. She is well published with more than 200 referred scholarly articles, several 10 books, numerous book chapters, an encyclopedia and a well established funded research track record.

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