Q&A: In Germany, success in digital health must be built on trust

According to ZS’s 2024 Future of Health Report, overall digital health use in Germany was the lowest of all six countries we surveyed except Japan—despite the fact that Germany has been a pioneer in digital health reimbursement. Legislation, such as the EU’s AI Act and Germany’s DigiG (which enables ePA), GDNG and the Hospital Transparency Act, has the potential to not only improve adoption of digital health but also enable a more patient-centric healthcare system.

To discuss the impact of the new legislation and the opportunities that digital and AI solutions have in the German healthcare market, we continued our conversation with ZS Associate Principal Eva Struckmeyer and Manager Kevin Santo, both based in ZS’s Frankfurt office.

ZS: Overall, digital health usage is relatively low in Germany compared to other countries, and consumers are more likely to report barriers to digital health adoption, despite tools like DiGAs. What’s holding back adoption, and what will it take to see the impact of legislation like the GDNG and the Data Act?

Kevin Santo: There are a lot of digitalization efforts in Germany, but there’s still a long way to go. About 95% of office-based physician communication is within traditional channels like phone, mail and fax, while 5% is through digital channels. I think the COVID-19 crisis showed us that there are alternative ways. And even some of the latest research suggests that both hospital and office-based physicians are very open to using digital channels in their communication.

The GDNG is a good first step to make the data treasure we’re all sitting on available to build the basis for the first centralized data platform in Germany for research and development purposes. It’s also important to bring the industry along and make sure that all these data owners—not just the public but also the private ones—work together. We need to create a trustworthy environment for all the parties involved. With the rise of generative AI, there’s a significant opportunity to build on this data and for the German healthcare system in particular to achieve better patient outcomes and save costs.

Eva Struckmeyer: I think I would go as far to say that Germany, at the moment, is still a digital no man’s land. The European Commission has a digital economy and society index that looks at connectivity, human capital, internet usage, integration of digital tech, media and so on. It ranks Germany as third to last place in Europe. It shows how much must be done in terms of the digital infrastructure in Germany, especially in terms of building trust in digital.

I looked up the number of German households that have an Alexa or similar digital virtual assistants, and close to 9 million Germans have one. They aren’t bothered that all of their conversations are being listened to. However, they do worry about data privacy because that’s historically been an issue in Germany. It is almost as if people have been programmed to bring up data privacy.

So, Kevin’s point about trust is an important one. The GDNG set up a data trust center, which is obviously really important. I think people also need to see the value in sharing data for clinical study purposes and recognize that their own case data will be of help for others in the future.

In a product ZS is piloting in Germany right now, Data Nexus, we’re asking hospital patients to share five years of retrospective and forward-looking data. We developed this product with proprietary capabilities that enable an unparalleled level of data linkage and integration across care settings including hospitals, office-based practices and insurance networks. It connects deep clinical data, such as imaging and genomics, with patient-generated wearables and digital health app data. We’re seeing a 78% opt-in rate across users, and for some categories even 90%. If the need and value of sharing data is communicated to patients, then it makes sense to them, and the everlasting data privacy argument is out of the way.

This approach to data sharing unlocks new and innovative research possibilities. For example, it allows for the connection of clinical outcomes data with patient well-being data through Patient-Reported Outcome Measures (PROMs). The depth of data available makes Data Nexus a single source for a broad range of data and evidence needs.

ZS: Germans, like consumers across markets, want more preventive care, and GPs want to spend more time providing it. How can digital health help meet this need?

ES: There are some lighthouses in terms of preventive care and what some digital apps do. There’s Ada Health, which is an AI-powered tool that helps people better understand their symptoms and find the right diagnosis. Pharma is also starting to shift its attention toward earlier and better diagnosis. Yet it is the healthcare system that has to change.

Digital health can help with this shift of the entire system toward more prevention. Right now, we have a healthcare system that’s caring for and curing symptoms, but we’re not preventing symptoms, at least not on a broad scale.

KS: I agree. Of course, GPs want to spend more time providing this preventive care, but they’re facing quite a challenging environment. There’s immense cost pressure in the system that requires HCPs to be more efficient in the way they deliver healthcare. And as a rule of thumb, this will also result in less time per patient and the current environment doesn’t really allow for that. To Eva’s point, this is where digital technology really can play a crucial role. That could be through the increased use of telemedicine, which we see potential and openness to in the German market, but there is still a long way to go to full acceptance.

ZS: How will the EU’s AI Act, which was passed at the end of 2023, help improve consumer and HCP trust through transparency in AI? And what are some specific barriers to trust that it can help overcome in the German market?

KS: When we look at the EU legislation objectively, I think it provides a certain level of security and builds a level of trust in the technology by banning unethical or government-owned applications.

To Eva’s point about the sensitivity of sharing personal data, especially health-related data, I think this law will build one cornerstone of Germany’s efforts to digitalize healthcare. It might not affect those who are already using it, but I think it might nudge the skeptics and make them more comfortable from a regulatory standpoint—or give them a starting point for digital and AI technologies. I also see it as a commitment at the EU and country level to further digitalize healthcare systems and improve health outcomes.

ES: I agree with all of that. Based purely on the fact that something is being governed or regulated in some ways gives people more trust. And as we alluded to earlier, trust is important.

ZS: Speaking of AI, what are use cases that hold the most potential and opportunity for providers, patients and healthcare professionals?

ES: I would refer to the paper ZS published with the World Economic Forum, which had three broad use cases for gen AI, including health education and assistance, copilots for patient triage and disease management interventions. Considering some of the challenges Germany is having in healthcare at the moment, I think AI can help labor shortages here and in many other countries. If we can use AI solutions to free up time, labor and effort in the right places, I think it can do a lot—but it will require that the positive benefits are communicated well.

KS: The most prominent examples we’re currently seeing in Germany, when you look at the patient journey, are at very specific intervention points. For example, there’s a German diagnostic and dermatology app called Dermanostic that’s getting a lot of attention because it facilitates telemedicine and detects dermatology disorders through AI.

But I think the biggest opportunity lies in connecting the dots across the healthcare ecosystem in Germany. We should be looking to build an end-to-end patient care pathway that is supported by AI and technology across all these different intervention points that you see from symptoms recognition to diagnosis, treatment initiation, up until ongoing treatment maintenance.

Q: You’ve talked a lot about the relationship between the patient and the Hausärzte. But what are some challenges with specialists in Germany?

ES: Access is very tough and getting worse. I’ve seen cases where people, despite having an acute heart condition, didn’t get access to cardiologists until two months had passed. Sometimes, if you’re privately insured or you can self-pay, you get access. It looks democratic on the surface, but if you look closer there are some disparities that will probably increase in the future.

KS: A broader trend that we are seeing in Germany is the consolidation of the outpatient sector where, on the one hand, private equity is buying a lot of outpatient centers. On the other hand, the big hospital chains in Germany are also buying outpatient centers and even closing some of the smaller clinics and replacing them with outpatient centers. What they’re trying to do is keep the patients within their own system across inpatient and outpatient settings.

Once you enter the system through the GP or through a certain specialist, the likelihood is pretty high that you are getting referred within the system. To Eva’s point about health disparities and not getting access to physicians, my hope would be that for patients within those systems, the advantage is that they would get better access to those specialists. But whether this will happen remains to be seen.