Implementing Digital Transformation: Lessons learned from Germany and England

The past three years have shown how technology and data play a critical role in helping countries across the world to deliver safe and effective care to patients, reduce health inequalities, and direct limited resources appropriately. The pandemic accelerated the pace of digital advances in health: in terms of remote consultations, online access to health information and treatment. It also exposed the health inequalities that persist and the need for user-centered solutions to meet the needs of all groups.

Although Germany has one of the best healthcare systems in the world, it recognizes that it trails other countries in digital health maturity. In March 2023, the federal health ministry published Germany’s Digitalization Strategy for Health and Care. In this, Karl Lauterbach, the federal health minister stated, "When it comes to health and care in Germany, digitalization carries huge potential that has hardly been used to date."In October 2023, Lauterbach and colleagues also launched the development process of the action plan for a diverse, inclusive, and barrier-free healthcare system. “Barriers to access to healthcare facilities, language barriers, or discrimination,” argued Lauterbach, “There can be different barriers that make it difficult for people to access care. We want to change that... The best healthcare won't help if everyone doesn't have access to it.” In implementing the digitization strategy, Germany has a unique opportunity to align this with the delivery of a diverse and inclusive healthcare system: where there is equal access and a focus on removing discrimination.

How will digitization be implemented?

The strategy sets out several key objectives and priorities that include an electronic health record; a complete, digital medication overview for insured persons; higher quality, faster availability, and more legal certainty in relation to data use; data protection and data security; a lifting of restrictions on telemedicine to 30 percent of consultations; and a refresh of Gematik GmbH aims and accountabilities.

The targets include:

• by 2025, 80 percent of statutory insurance holders will have an electronic patient record;
• by 2026, there will be an assisted telemedicine access point in at least 60 percent of regions with insufficient access to general practitioners;
• in 2026, 80 percent of communication processes in healthcare will be paperless.

In August 2023, the federal cabinet approved the drafts of an Act to Accelerate the Digitalization of the Health Care System (DigiG) and an Act to Improve the Use of Health Data (GDNG). The timeframes for implementation of the objectives are ambitious, particularly in the light of previous attempts to digitize healthcare over the last ten years, the current data silos and opposition to some of the changes from key stakeholders in the healthcare system.

I spent three months in Germany in the summer of 2023 analyzing Germany’s approach to digitization and comparing it to England’s. I spoke to a wide range of stakeholders including clinicians, patients, insurers, and digital leaders about the current use of digital and data tools.

My feedback from stakeholders included the likes of:

• “The IT team is a helpdesk,” said a clinician involved in digital health.
• “We have been talking about [an electronic health record] for more than ten years,” said a digital leader.
• “No one can share health data at scale in Germany,” was said at the BMG digital conference, Berlin, June 2023.

Clinicians largely use paper records to communicate with one another with minimal data-sharing or interoperability. For example, GP referrals are still faxed to hospitals. Less than one percent of patients have access to their electronic health record. The healthcare landscape is highly fragmented, with variable continuity of care. Patients are generally free to see any primary care or specialist services of their choice. As a result, data in primary care, hospitals, and insurers sit in siloes. This restricts the ability to analyze data at a population level and thus to guide decisions and plan health services. 

Digital adoption and maturity is harder to achieve in highly devolved administrative states such as those found in Germany because of the complexity of achieving national consensus. Digital leadership, clinical engagement, and support for digitization is variable, and like the NHS, there is a rapidly growing informatics skills gap. Unlike the NHS, there is no coordinated plan to develop the digital workforce, grow expert informatics capacity, or build networks of digital health leaders.

Despite ever more international recruitment, there is also minimal diversity in leadership and a lack of data on ethnicity and health. This contributes to and can exacerbate health inequalities and bias. For example, in the US and UK maternal health is among the starkest examples of racial health inequality. In the UK, women from Black ethnic backgrounds remain four times more likely to die in pregnancy compared to White women.

There are also significant differences in morbidity and mortality rates in some ethnic groups, for example from Covid and cardiovascular disease, as well as severe disparities in terms of access to mental health treatment. The data vacuum in Germany means that no one knows whether patients from minority ethnic backgrounds have a different experience of healthcare, clinical outcomes, or incidence of disease. We were also unable to find a single senior digital leader in healthcare provider organizations such as hospitals and community clinics who identified as female and as a person of color. Yet, 24 percent of the wider population have an immigration history, and the healthcare workforce is predominantly female.

How can digital innovations also deliver a diverse, and barrier-free healthcare system?

I spent 30 years in the healthcare profession in England as well as the U.S., Laos, Indonesia, and Sudan. I lead and implemented national health policy, digital programs, and integrated models of care. Here are several key recommendations that will help countries including Germany implement digital change at scale:

1. Start with population health needs, not the technology

It is very tempting to think that a new app, software, AI algorithm, or other product that once implemented will solve the challenges in health and care, without considering the problem that needs to be solved or engaging the people affected, namely patients and staff.

What drives digital transformation? The goal should be to deliver the fivefold aim outlined by the Institute for Healthcare Improvement:

• improving the health of the population;

• enhancing the experience and outcomes of the patient;

• reducing per capita cost of care for the benefit of communities;

• increasing workforce well-being and safety;

• advancing health equity.

Delivering this without utilising digital and data enablers, or implementing large-scale digital change without placing the goals at its core would be counter-productive. Essential from the beginning are clear metrics to track progress and impact, as well as robust clinical safety and governance processes.

Lessons have been learned from implementing other major transformation programmes in healthcare. With digitisation there are unique additional dimensions that add to the complexity, such as information governance, cyber-security, AI and data protection. Significant incidents involving digital and data have the potential to affect millions of people and cripple health services. Rapidly evolving technological advances mean that the ability to identify future trends, flexibility, and adaptability will be increasingly important for health and care systems across the world.

2. Invest in digital workforce and leadership

Implementing change at scale in health care will not happen by magic or legislation alone. It is hard enough convincing clinicians in one clinic to adopt change, let alone changing behavior on a national level. Germany needs to develop digital champions and credible informatics experts, offer support for all staff to develop confidence in using technology, and senior leaders who are able to build trust and consensus.

At NHS Digital, I led the largest team of clinical informatics experts in England who were from a wide range of backgrounds and worked on over 70 data and digital programs. This helped the NHS to successfully launch and maintain national digital products and services such as the NHS website, app, electronic referrals, e-prescriptions, and online vaccination booking systems used by millions of people.

The NHS plan for digital health and social care in the UK makes it clear that: “To achieve digital transformation, we need to build general digital literacy, expert digital skills, and digital leadership in the health and social care workforce.” A national digital workforce plan will be published by NHS England. Programs including the NHS Digital Health Leadership program and the Shuri Digital Fellowship have helped to build the next generation of digital leaders. The Topol Review also made recommendations on how to prepare the healthcare workforce through education and training.

Digital and data careers are also often seen as exclusive, with unclear career entry points and job descriptions that can discourage applicants from under-represented groups such as women from applying. This needs to change as we are not fully harnessing the talent and potential within our teams. Equal opportunities to progress and the elimination of gender and ethnicity pay gaps are essential if we are to attract and retain the most skilled people in this field.

3. IT is more than a helpdesk

Data and informatics should be seen as part of the strategic leadership of healthcare organizations. When reforms of the wider health system are discussed, data and technology leaders should be around the table to ensure an integrated, evidence-based approach, and clear alignment between health and informatics priorities.

4. Get the basic infrastructure right

For many of our staff in healthcare, IT creates an added burden: outdated equipment, poor connectivity, multiple logins, a lack of interoperable records, and inadequate training to use digital tools. This, on top of high-pressure jobs leads to an adverse effect on staff morale, wellbeing, and therefore patient care.

Health and care systems need to invest in the infrastructure (hardware, software, connectivity) to enable staff to work more efficiently and effectively. Talking about robotics, wearables, genomics, and AI is all well and good, but when your staff struggles to access patient records because the wifi is too slow, patient outcomes are directly impacted.  What is not clear is how much investment will be required to implement the digital strategy in Germany, and who will bear the costs given the complexity of the transformation and the current digital maturity.

Final thoughts

The technology might work brilliantly but what patients remember most is how they are treated. The next few years are an opportunity for Germany to redesign how healthcare services are delivered, utilizing data and technology to increase health equity, innovation, efficiency, communication, reduce discrimination and support research. Using legislation and national incentives strategically, engaging stakeholders, learning from other health systems and keeping people, not technology, at the heart of digital transformation will increase the chances of success and deliver the changes the population deserves.