eCard - developments in Germany

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

A "slim" version of the long-planned Electronic Health Card (eCard) has recently been launched in seven pilot regions all over Germany. This ambitious eHealth-project is highly controversial due to technical difficulties, questions of data protection and constantly rising costs. Together with healthcare payers and providers, the MoH has been working on the card's introduction since 2005.

Purpose of health policy or idea

An Electronic Health Card is expected to bring benefits for both patients and the health system. The Ministry of Health, major driving force of eCard implementation in Germany, expects the eCard to bring benefits for both patients and the healthcare system. Main expectations are as follows: 

Patients will benefit from better coordinated care and access to their own health data: 

• Damages due to unwanted interaction of prescribed drugs can be minimized.
• Emergency treatment can be improved, as emergency data like blood group, allergies or drug intolerances can be stored on the card. 

Improved transparency and access to their own health data for patients:

• Patients will be given the possibility to administer their own health data. Access to the stored data will only be feasible with authorization of the patient.    
• Patients administering their own health data will be in a better position to act as partners on an equal level when interacting with health professionals.      
• Improved transparency for patients, who will be able to access their own health data, once it is stored on the card. "eKiosks" - computer terminals which will allow access to data stored on the eCard - are supposed to be set up in physicians practices and pharmacies. Whether the data will be accessible for patients with their eCard and PIN or only in combination with a physician's Health Professional Card has not been decided yet.  

In the long run, cost savings are expected: 

• The immediate availability of health data via eCard to all health professionals a patient consults with will reduce the number of unnecessary diagnostic services. In the German healthcare system with its low degree of coordination between providers, the number of diagnostic services performed on a patient multiple times by different providers is supposed to be high.    
• The implementation of electronic prescription is expected to be more cost-efficient than the currently used paper prescription. 

After the roll-out - which is announced for the beginning of 2009, although this deadline has not officially been approved by MoH -, different eCard functions will be added gradually. A few of the planned functions have not yet been proven to work with the eCard. Therefore, the actual benefit of the eCard will depend on the final set of functions it is going to provide.  

Functions of the eCard  

The eCard will consist of both mandatory and voluntary functions, some of which will be introduced in later stages of the implementation process.  

As mandatory data, the eCard will comprise administrative data, such as patient's name, insurance and surcharge payment status, health insurance provider and date of birth. Additionally, mandatory functions of the eCard will include electronic prescription and the European Health Insurance Card as well as a picture of its holder.  

As voluntary data, the following functions are planned: Documentation of medication prescribed, emergency data like allergies and drug intolerances, and an electronic patient file including diagnoses, references to X-ray images, etc. Technical development of the electronic patient file, however, has not yet been completed. Since not all future functions of the eCard have yet been fully developed, the eCard will start with very basic modes of operation, similar to the functions of the existent health insurance card.  

Data protection aspects The eCard itself will only contain administrative and emergency data together with electronic prescriptions. Other data will not be stored on the card, but on the different servers of medical facilities, which the card - as a sort of directory -  will refer to via secure internet links. Access is only given if the patient's eCard and its corresponding PIN is applied concurrently with a physician's Health Professional Card (an electronic identification card for health professionals) plus PIN. For emergencies and for electronic prescriptions only, health professionals will be able to access a patient's emergency and prescription data by using their Health Professional Card as authorization; no second authorization by the patient is needed.  

This "two-keys-principle" allows patients to decide themselves who should gain access to which kind of their health data. Patients also shall get enabled to gain insight into their stored data using so-called "eKiosks" which are supposed to become installed at medical facilities (e.g. pharmacies or physicians practices). Details of eKiosk implementation and operation still have to be negotiated. All access to the data is recorded, with the 50 most recent accesses being stored.

Patients have the right to delete voluntary data, but only in the presence of a health professional. The final decision of deleting data lies with the patient. However, if health professionals perceive the deletion of certain pieces of information as critical, they can document the fact that information has been deleted from the card. 

Type of incentives

Payers, mainly the statutory health insurance funds, expect savings, primarily as a result of electronic prescriptions and reduction of unnecessary diagnostics. Legislation states that costs of eCard development and implementation have to be carried by health insurers. A first financial agreement has recently been reached between health insurances and the Federal Association of Statutory Health Insurance Physicians, saying that a sufficient amount will be provided by Private and Statutory Health Insurances to install card reading facilities in physician practices. Nevertheless, physicians still fear that they might be forced to invest in technical infrastructure, like additional software, without corresponding benefits for themselves. Furthermore, not all physician practices are sufficiently equipped with the necessary basics, like computers or internet connection. Physicians also expect that uncovered costs will arise from handling the eCard in their daily work, as well as expensive trainings for staff members. Concerning these expenditures, no agreements satisfactory to all parties involved have yet been found.

Groups affected

Patients, Providers, Payers

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

The eCard introduction is years behind its ambitious original schedule; planned implementation stages have been postponed several times. Further delays are likely, as the technical details as well as the project itself are still subject of heavy debates among stakeholders.

2002: The federal level associations of self-administration (provider and payer associations) agreed to jointly develop and establish an Electronic Health Card.  

2003: The Healthcare System Modernization Act was legislated, with the objective of downsizing ancillary wage costs. § 291 SGB V contains the legal framework for the introduction of the Electronic Health Card. It requires statutory health insurance providers to expand the previous Health Insurrance Card into an Electronic Health Card.  

Beginning of 2005: Federal level associations of self-administration (including prominent associations of physicians, dentists, hospitals, statutory and private health insurance funds) founded a corporation for telematics (gematik - Gesellschaft für Telematikanwendungen der Gesundheitskarte mbH), which is responsible for the quick introduction and future further development of the Electronic Health Card.

In 2005, MoH took charge of specifying framework conditions for the Electronic Health Card's implementation (Ersatzvornahme), as gematic associates could not agree on a joint approach, delaying the process of introduction and roll-out.

In 2005 and 2006, concrete schedules for pilot projects were legislated. The roll-out of the eCard in the first two pilot regions (Flensburg, Löbau-Zittau) for tests under real usage conditions started at the end of 2006.

Although legal foundations only address statutory health insurances, private health insurances will also implement the eCard on a voluntary basis. Private insurers are also part of gematik.  

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

Telematic solutions have recently been introduced into several countries' healthcare systems (see Electronic Health Card in Austria, Electronic medical records in France, National Health Information System in Estonia, Creation of an IT-based health care platform in Switzerland). Nevertheless, these systems differ in application, purpose and technical aspects. Also within Germany many varying telematic systems (e.g. electronic patient files) have been developed during the last years, most of them limited to a network of cooperating providers in a specific region, and certainly not talking to each other. Compared to similar project, the German eCard is very ambitious due to the number of functions and patients involved.

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Privatwirtschaft, privater Sektor

• Meinungsführer

• Andere

Approach of idea

The approach of the idea is described as:
renewed: Telematic solutions have recently been introduced into several countries? healthcare systems. Also within Germany many varying telematic systems (e.g. electronic patient files) have been developed during the last years.

Innovation or pilot project

Local level - Currently the following card functions are being tested in seven pilot projects all over Germany: handling of administrative and emergency data and electronic perscription; with data transfer working offline.

Stakeholder positions

Government

While strongly promoted by the MoH, the Electronic Health Card is subject to heavy debates among other stakeholders.  

Providers/ provider associations are divided into supporters, total refusers and facilitators who support the project in general, but oppose some aspects of its realization. A smaller physician group (e.g. the association of office-based physicians, NAV-Virchow-Bund) would prefer the data stored on USB flash drives to ensure patient-based control of the data (NAV-Virchow-Bund, 2008). The collection of health data is also perceived as a danger to doctor-patient confidentiality by some physicians. Some physician associations feel that the Electronic Health Card will be helpful in optimizing cooperation among providers and therefore improve healthcare for patients. However, in relation to costs and efforts necessary to implement the eCard, most physicians see medical benefits as minor.  

From the providers' point of view, the distribution of investment costs for the necessary technical infrastructure is also a critical point. As the use of the Electonic Health Card requires special technical equipment at hospitals, pharmacies and physician practices, providers suspect that they will be forced to pay for the required telematics infrastructure. Savings which are expected to derive from the Electonic Health Card in the long run will occur to the benefit of sickness funds. Providers therefore suspect an unbalanced allocation of costs and benefits at their expenses.  

To balance this inequity, first financial arrangements between payers and providers have been agreed upon, concerning financial support for necessary technical equipment. Nevertheless, this agreement has not comforted all concerns among providers, as many financial questions remain unsolved. Additionally, physicians anticipate delay in their daily work if they have to deal with the Electonic Health Card and requests from patients to access their own data.  

Individual opinion leaders: Karl Lauterbach, medical expert of the Social Democratic Party, accuses physicians of not admitting their true reasons for opposing the eCard. In his opinion, physicians have been continuously opposing the Electronic Health Card in order to prevent more transparency in the healthcare system. He claims that the current (unsystematic) way of handling patient health data and passing it from one provider to another is a bigger threat to patient health data safety than the planned functions of the Electronic Health Card, which will inhibit access to data without the patients approval.  

Patient groups: Only very few comments have been issued from patient groups.  

Data protection specialists like Schleswig-Holstein data protection officer Thilo Weichert, generally have no objections against the eCard. The standard of data protection precautions is perceived as high enough to prevent unauthorized access to the health data, as most functions are voluntary and patients will be allowed to administer their own data (Weichert 2008). Critical voices are raised by information technology experts, like the Chaos Computer Club (an association that promotes more transparency in governments, freedom of information and a human right to communication), whose members oppose the data storage on a server, but not the card itself. CCC members point out that centrally stored data might not be safe enough to prevent unauthorised attacks on information as sensible as health data (Chaos Computer Club, 2008).  

Industrial Associations, mainly the German Association for Information Technology, Telecommunications and New Media (BITCOM) and technology providers like Siemens AG, are strongly supportive of the project. According to them, the German Electronic Health Card might likely become a model of interest for other countries leading to possibilities to export this product.

Actors and positions

Regierung
Ministry of Health	sehr unterstützend		stark dagegen
Leistungserbringer
National Association of Statutory Health Insurance Physicians	sehr unterstützend		stark dagegen
NAV-Virchow-Bund, (Small Association of office-based physicians)	sehr unterstützend		stark dagegen
Association of independent physicians	sehr unterstützend		stark dagegen
Privatwirtschaft, privater Sektor
BITKOM - German Association for Information Technology, Telecommunications and New Media	sehr unterstützend		stark dagegen
Meinungsführer
Professor Karl Lauterbach	sehr unterstützend		stark dagegen
Andere
Data protection officials	sehr unterstützend		stark dagegen
Chaos Computer Club	sehr unterstützend		stark dagegen

Actors and influence

Regierung
Ministry of Health	sehr groß		kein
Leistungserbringer
National Association of Statutory Health Insurance Physicians	sehr groß		kein
NAV-Virchow-Bund, (Small Association of office-based physicians)	sehr groß		kein
Association of independent physicians	sehr groß		kein
Privatwirtschaft, privater Sektor
BITKOM - German Association for Information Technology, Telecommunications and New Media	sehr groß		kein
Meinungsführer
Professor Karl Lauterbach	sehr groß		kein
Andere
Data protection officials	sehr groß		kein
Chaos Computer Club	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The introduction of the Electronic Health Card will take place in several stages, regarding both number of card functions and stakeholders.  

The card is being tested under laboratory conditions since the end of 2005. At present, basic functions are being tested under real use conditions in seven German regions; the first two pilot regions, located in Saxony and Schleswig-Holstein, started distribution and testing of eCards in December 2006. On average, about 10.000 insured persons, 25 physician practices, 15 pharmacies and two hospitals are testing the eCard in each pilot region. Currently, first results of these pilot tests are being discussed, as the card does not yet meet all practical requirements: Elderly, handicapped and people who are not familiar with smart cards showed major difficulties in the handling[i]. According to previous proclamations, the number of issued eCards will be increased to 100.000 per pilot region. Furthermore, additional functions shall be adopted, as at this stage, only offline functions have been tested in the pilot studies, e.g. handling of administrative and emergency data and electronic prescriptions.

[i] Detailled information on the pilot regions is available at: "Im Labor und in den Testregionen": www.die-gesundheitskarte.de/gesundheitskarte_aktuell/testphase/index.html (German) and at www.telematik-modellregionen.de (German).

Monitoring and evaluation

So far, the pilot studies yielded mixed results.  

• Physicians in the northern test region, Schleswig-Holstein, stepped out of the eCard testing phase of emergency data, as a majority of patients, especially elderly or handicapped, were not able to enter the PIN during the time frame dictated by the electronic equipment. Thus, debates have evolved on whether physicians should be allowed to enter the PIN on behalf of a patient (Working group eCard Schleswig-Holstein GmbH, 2007) - an issue still unsolved. 
• Physicians in the Saxon test region worked successfully with the eCard in a pilot of 10.000 patients. However, when MoH proposed to extend the number of pilot participants to all Saxon physician practices and later to all patients, the chamber of physicians refused to do so, claiming they did not expect any additional benefit from the eCard functions currently available. Some demands to increase eCard functions as soon as possible have been raised by physicians, but too many technical aspects are not yet ready for application.  
• So far, no official outcomes from other pilot regions have been reported.

Expected outcome

Examples from other countries show that information technology in the healthcare system can be a helpful tool to improve health care and gain benefits for patients and other stakeholders. Nevertheless, the implementation process of the Electronic Health Card has so far not been too successful, partly due to the dimension of the project, partly due to delayed schedules, highly unrealistic cost estimates and insufficient cooperation among stakeholders. As acceptance of the card is crucial for the success of the project - after all, it lies within a patient's decision to actually use all eCard functions - gaining acceptance among physicians and patients should have been more of a focus to the authorities.  

Some important aspects still need to be clarified, e.g.:

• What kind of facilities need to be provided for patients to get access to their stored data, without delaying daily work in physicians offices?
• Which overall costs - investments as well as running costs - will arise from the implementation?
• Who pays for additional expenses, like staff trainings?

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Once all functions of the eCard are implemented on a national level, quality of healthcare services can be expected to improve fundamentally. Cost efficiency is hard to predict, since final costs and financial outcomes of the eCard are not yet clear.

References

Sources of Information

• Federal Ministry of Health. Die Gesundheitskarte. www.die-gesundheitskarte.de/ Website providing information on the eCard (German). English summary available at www.die-gesundheitskarte.de/download/dokumente/broschuere_elektronische_gesundheitskarte_engl.pdf.
• Nav-Virchow-Bunde.V. Positionspapier der niedergelassenen Ärzteschaft zur elektronischen Gesundheitskarte. April 2008. www.nav-virchowbund.de/images/data/Stellungnahme_eCard_DAeT.pdf (German).
• Freie Ärzteschaft e.V. Die Krankheitskarte. Risiken und Nebenwirkungen. June 2008. www.diekrankheitskarte.de/index.php?/plugin/dlfile_22 (German).       
• Chaos Computer Club e.V. Chaos Computer Club warnt vor unabsehbaren Risiken bei der elektronischen Gesundheitskarte. March 2008. www.ccc.de/press/releases/2008/20080316/ (German). 
• "Die Ärzte fürchten Transparenz". Interview with Karl Lauterbach. Die tageszeitung. January 24th, 2008. Awww.taz.de/1/zukunft/konsum/artikel/1/die-aerzte-fuerchten-transparenz/?src=SZ&cHash=dd1eace76b&type=98 (German).
• ARGE eGK.SH GmbH. Die Gesundheitskarte Schleswig-Holstein. www.gesundheitskarte-sh.de.
• Projektbüro. ARGE SaxMediCard. ARGE SaxMediCard - Projekt des Freistaats Sachsen. www.saxmedicard.de/saxmedicard.php.
• Telematik Modellregionen. Testregionen für die elektronische Gesundheitskarte. www.telematik-modellregionen.de.
• Verband der privaten Krankenversicherung e.V.: Die elektronische Gesundheitskarte in der privaten Krankenversicherung. www.private-gesundheitskarte.de/broschueren_materialien/pkv_broschuere_zur_einfuehrung_der_egk.pdf (German).  

Author/s and/or contributors to this survey

Dittrich, Kerstin

The author holds a degree in psychology and works at the Eastern German Chamber of Psychotherapists. This survey was written during an internship at the Bertelsmann Stiftung.

Reviewers: Jürgen Sembritzki, ZTG - Zentrum für Telematik im Gesundheitswesen GmbH, and Sophia Schlette, Senior Expert Health Policy, Bertelsmann Stiftung.

Empfohlene Zitierweise für diesen Online-Artikel:

Dittrich, Kerstin. "eCard - developments in Germany". Health Policy Monitor, June 2008. Available at http://www.hpm.org/survey/ger/a11/1