E-patient file: Time and trust could be lost

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After 20 years of stagnation, things are now set to move quickly. Lauterbach invokes the "race to catch up in digitization". Digitization is the future of good medicine, said the Federal Minister of Health. Our practices have long been digitalized. The diabetes patients in my practice wear blood glucose sensors and share their data with me in real time. Their insulin pumps work with algorithms that automatically regulate their blood sugar. These are real improvements.

The telematics infrastructure (TI), digital networking in the healthcare sector, should become the digitalization turbo. However, I had serious problems with the installation of the technology ("connector"), which had to be solved with countless remote maintenance sessions and a great deal of time and money. To this day, there are still problems with the TI in many practices, and only recently there was another major e-prescription malfunction. 43 percent of practices report weekly failures, 15 percent even report daily problems (IGES survey). The quality of implementation depends very much on the respective doctor's software.

E-prescription still not running smoothly

When patients are in my consulting room, I send their e-prescriptions immediately. When they come to the counter for a follow-up prescription, the medical assistant places the e-prescription on a digital stack and I sign and send the e-prescriptions between treatments. The nearest pharmacy is so close that some patients arrive there before I have had a chance to approve their prescriptions. Then the prescription is not "on the card" for the time being. The advantage is that follow-up prescriptions can be ordered by phone and sent by us as an e-prescription without direct patient contact.

For me, it still takes 14 seconds to sign an e-prescription, which is longer than printing out a paper prescription. Aids, over-the-counter medicines, private prescriptions and anaesthetics are not yet available as e-prescriptions and still have to be printed out on paper for the time being. For patients of nursing homes and outpatient care services, we fax printed e-prescriptions to pharmacies because a direct electronic referral to the pharmacy is not possible in my doctor's software.

Anyone in possession of a valid insurance card can scan it in any pharmacy or doctor's surgery and order prescriptions or have the card holder's findings printed out. It is not necessary to enter a PIN. I see a certain potential for misuse here.

The data treasure trove of the "ePA for all" is to be exploited

Karl Lauterbach is pushing for the introduction of the electronic patient file "ePA for all". However, IT specialists refer to the ePA as "dark green shrivel banana software". Prof. Sylvia Thun – a proven expert in the field of documentation – described the ePA as a "complicated dropbox for PDF documents". The German Health IT Association (btvig) warned against a hasty introduction: the software is not fully developed and has not yet been sufficiently tested.

Nevertheless, the statutory health insurance funds will create an ePA for their policyholders from January 2025. However, doctors will not have to enter any data for the time being. The obligation will be postponed until tests in model regions are successful. Incidentally, hardly any patients have asked me for an electronic health record so far.

Back to paternalism?

Furthermore, fine-grained authorization management for patients will not be implemented for the time being, even though the circle of authorized users is growing. Deutsche Aidshilfe has criticized the fact that individual diagnoses or medications cannot be deleted in the ePA. TK boss Baas replied that no progress would be made with decisions made by such interest groups. Since the ePA is supposed to be a patient-managed record, such a statement seems paternalistic – and we always talk about "patient empowerment". Insured persons should be actively informed about every access to their electronic health record without exception in order to be able to recognize possible misuse. For example, there are also e-mail notifications for unusual login attempts for accounts on Google and the like - why not for the EPR too?

An independent second opinion can be made more difficult by the ePA. People with mental illnesses are at risk of stigmatization or similar. If the data were to fall into the wrong hands, this would have serious consequences for those affected.

The ePA will fundamentally change the doctor-patient relationship and it is to be feared that this will not always be for the better. If patients refuse access to their electronic health record in future, it will be almost impossible to work together in a spirit of trust. It seems as if health insurance companies want to use their policyholders as deputy sheriffs to detect billing fraud by doctors in the ePA.

Many authorized users

The circle of people authorized to access the ePA is large and is constantly expanding. In addition to medical, dental and psychotherapy practices and clinics, which automatically have access to the contents of the ePA for 90 days after inserting the health card, pharmacies will also have access for 3 days. Outpatient care services and physiotherapists will be added later.

The ePA could be problematic for healthcare workers who undergo examinations at their workplace, for example in a large radiology practice. If they do not want doctors or staff to find out about their depression, for example, they must remember to block access to the ePA in good time.

High time expenditure feared

I expect the "ePA for all" to take up a lot of time for the obligatory filling, viewing of PDF documents, rights management and patient education. I am also concerned about liability issues: what happens if I overlook an important finding in the ePA and this results in a treatment error? How do I react in the event of data loss?

The emergency departments of hospitals will definitely benefit from having round-the-clock access to the ePA. This means that important information is available to them more quickly and no longer has to be laboriously requested from the GP by fax. Clinic reports could also be available to me more quickly thanks to the ePA. If the patient has forgotten the discharge report, I can find it in the ePA if it has already been written and uploaded.

Above all, it is important that doctors in private practice and clinics have stable, functioning technology and user-friendly applications with the highest security standards. However, it should not be forgotten that digitalization is not an end in itself and does not automatically improve medicine.

(nie)