Looking Across the Atlantic at the Interoperability Challenges in Europe

Aug. 31, 2023
Looking at some of the data interoperability and analytics challenges facing leaders in the German healthcare system reminds one of how global the overall struggle is

It is fascinating to scan what’s going on internationally in healthcare and healthcare information technology and interoperability, as every single nation on earth is struggling in some way and to some degree, in all of those areas. And while the leaders of the U.S. healthcare system continue to struggle with a level of policy, payment and regulatory fragmentation that can be absolutely baffling for foreigners to try to understand, leaders inside the U.S. healthcare delivery system have made some strides that put our system ahead of those of some of the most progressive European national healthcare systems.

Comparing and contrasting the American and German healthcare systems is particularly fascinating; on the one hand, basic primary care is available to virtually everyone in Germany, including non-citizens. And though it has its complexities, the German health insurance system works, and nearly everyone is taken care of. And it is stronger for not having to rely on employer sponsorship for the coverage of non-seniors, as the health insurance cooperatives that insure most people there are not directly tied to employment.

Still, when it comes to electronic health records and especially to the use of operational data to help guide utilization and operational decision-making, U.S. patient care organizations are far ahead of their German counterparts.

There’s a lot going on right now in Germany, as the federal Health Minister for that country, Karl Lauterbach, is trying to guide the German healthcare system forward in a number of areas, including around interoperability; and it’s all turning out to be very complicated.

An incisive look at the situation appeared in today’s “Die Zeit,” the prestige Hamburg newspaper, under the headline “Digitization in healthcare: It will work out” (“Digitalisierung im Gesundheitswesen: Wird schon schiefgehen”), reported and written by Christian Endt, begins thus: “How many free beds are there currently in Germany's hospitals? How many nurses to care for patients? And how many people are currently infected with the corona virus? If you can't answer these questions, that doesn't seem to matter. Summer is still here. But the German Hospital Society is already warning of a winter in which cases of infection - not only with Corona - could put a strain on the health system. It is therefore not so good that no health minister, no expert council, no research institute, knows the answers to these questions. Even at the peak of the pandemic the year before last, when hundreds of people in Germany were dying every day as a result of a corona infection, nobody knew the answers.”

Endt continues, “Germany has excellent hospitals and doctors; Hardly any other country in the world spends more money per capita on health. A great deal is being done at the individual level, with a view to the individual patient. But when it comes to fundamental questions, such as prevention or a targeted, forward-looking use of medical resources, much less happens. Also because there is a lack of digital infrastructure for the healthcare system and there is a lack of data. The digital patient record? Was pushed forward with great delay. A digital public health service? Many experts have since given up. A systematic recording of the infection process? Often requested but never implemented.”

And, a bit further on, Endt notes that “Germany is still the land of patient folders made of pink cardboard, of reports being sent by fax, of eternal data protection concerns. Other countries are in a much better position. They collect data digitally, and they exchange and evaluate it for the benefit of all. These findings are not new. The shortage was repeatedly complained about during the pandemic, by researchers, journalists, and occasionally also from politics. But in the two-year long emergency, it was difficult to tackle the fundamentals. Then came war and the energy crisis. But now it would actually be time to look back and then forward: What should be improved? And where does that even work? Specifically: What has to happen so that Germany is better prepared for the next pandemic?”

What’s interesting is how profound the issue became during the COVID-19 pandemic, in Germany. Yes, in the United States, the public became aware that we lacked (and still lack) a true nationwide federal public health biosurveillance data-gathering and -reporting system that can effectively collect and share data in situations like the COVID-19 pandemic. But in Germany, there isn’t even anything at the state level. As a result, Endt writes, “In Germany, tests were essentially only carried out in suspected cases, i.e. in people who had contact with an infected person or who had noticed symptoms of the disease themselves. No one can say how many cases went undetected. There was also a considerable time delay, because in many health authorities, every notification arrived by fax for a long time and an employee had to type the information first. The unprocessed faxes often piled up in the offices. The result: At no time during the pandemic did authorities or researchers know how many people in Germany were currently infected. German scientists have repeatedly pointed out the problem publicly and in discussions with the federal government - and promoted the British model as a solution.”

After sharing perspectives from several experts, Endt writes that “Great Britain serves as a model here again. There, as a reaction to an outbreak of mad cow disease, the Scientific Advisory Group for Emergencies (Sage) was formed, which has since been advising the government on epidemics, but also after natural disasters. ‘A structure with such a body helps separate knowledge and interpretation," says Sebastian Funk, who has attended Sage meetings. "Sage focuses on compiling the scientific evidence and largely eschews policy recommendations.’ In any case, it is often not possible to agree on political measures in the group - but on the underlying facts.”

There are, however, even deeper basic problems in Germany. As a McKinsey & Company article entitled “German e-health offerings expand, but adoption remains uneven,” and published on Dec. 16, 2022, notes, “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,” the article, authored by Martin Lösch, Florian Niedermann, Hilke, Thomas Müller, Pirkka Padmanabhan, Laura Richter, and Tobias Silberzahn, notes.

“In addition,” the McKinsey analysts write, “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,” the article notes.

Indeed, the McKinsey analysts write, “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. 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).”

Hospitals, at least, are doing better. The McKinsey analysts note that “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.”

The bottom line in all this? It is clear that every advanced industrialized nation is struggling to move forward in all these areas—nationwide electronic patient data infrastructure, interoperability, patient-facing support, and public health biosurveillance. And there is no easy answer to any of the questions or challenges. At least, reading about what’s happening in Germany provides a degree of reassurance that we here in the United States aren’t the only ones struggling with these big healthcare IT issues; the whole word is.