The German ministry of health is set to introduce electronic health cards to 70 million members of the public health insurance system from 2008 onwards. Jens Naumann, head of the main German industrial association of health IT companies (VHitG), talks to E-Health Europe’s Philipp Gratzel about preparations for ‘day X’.

The recent political decision to start the German smartcard roll out in the second quarter of 2008 has come as a surprise to many. Was it the right decision?

Jens Naumann: “The announcement was followed by some highly emotional reactions. Doctors fear that the smartcards won’t work in practice. IT companies fear that the rollout of “smartcards and card readers only” will result in a severe delay when it comes to the implementation of the online system later on. The VHitG is a bit more relaxed about the whole thing: we do not fear that the German health IT project will run into a dead end, but rather consider this decision to be part of a migration strategy that can make sense. We are not talking about revolution any more, but rather about evolution. This is good news.”

Criticisms among doctors have increased in recent weeks. Some professional associations are talking about a boycott. What has to be done to keep the doctors on track?

Jens Naumann: “Most importantly, a decision has to be made about who pays for the hardware and software. Doctors in the seven pilot regions have received Euros 6,200 each for the necessary investments in software and infrastructure. But there has not been any decision so far about how to deal with the more than 100,000 doctors in private practice outside of the pilot projects.

“Secondly, we have to succeed in convincing them that the electronic health card and the national health IT infrastructure are two separate things, at least in parts. Doctors can use the infrastructure to send electronic discharge letters or referrals, and they can use it for accounting issues. These are real benefits for doctors, and they have nothing to do with all the arguments about how to sign electronic prescriptions or access electronic patient records.”

The one thing that is needed for electronic discharge letters, or for electronic referrals according to German law, is an electronic health professional card that is capable of qualified electronic signatures. Such a card is still not available, and it is not part of the smartcard rollout next year. Why?

Jens Naumann: “The national health IT organisation, gematik, has still not answered all relevant questions when it comes to the technical specification of the smartcards for doctors. That said, the Bundeszahnärztekammer (professional association of dentists) has recently decided to use preliminary health professional cards which can be used on the national infrastructure during the first years. This is definitely an option.

“In my opinion, the Bundesärztekammer (professional association of doctors other than dentists) should go the same way, because then we as IT vendors could finally make interesting offers to them. We desperately need electronic online communication for doctors. For their accounting, for example, most doctors still use floppy discs. Do you have any idea how difficult it is for IT vendors to get floppy discs these days? This is not sustainable any more.”

The VHitG has developed a standardised format for electronic discharge and referral letters in recent years. The standard is implemented in many IT solutions now, so why is everybody still using paper?

Jens Naumann: “Same reason again: Doctors have to have the possibility to sign documents with a qualified electronic signature in order to drop paper completely. That is what the electronic health professional card is all about.

There is a number of projects that in fact use electronic discharge letters and referrals according to VHitG standards, but the problem is identification and signature. Some of these projects use PIN/TAN identification, others use a tamagotchi-like password generator in order to identify the sender. Some use proprietary smartcard solutions. This is all nonsense, but there is no other possibility at the moment as long as the health professional cards are not out there. Things might change next year, though: There is a gematik decision now to realise electronic referral letters as the first medical application of the national infrastructure. So the political drive is increasing.”

Apart from a standardised form for electronic discharge letters, a national IT infrastructure will need a standardised medical nomenclature sooner or later. Will there be a VHitG-SNOMED-project?

Jens Naumann: “No. I do not think that solving this problem is part of the job description of a health IT association. A standardised medical nomenclature is a medical issue and has to be agreed on by the medical establishment. If there is ever a national project on medical nomenclature in Germany, be it SNOMED or anything else, industry will help in implementing it. But we will not do it ourselves.”

Nomenclature aside, it is still not clear how the ‘landscape’ of electronic patient records in Germany will look in the future. There are many different projects, even among VHitG companies, is industry doing anything to standardise these efforts?

"Full interoperability is science fiction"

Jens Naumann: “I think the vision of a national infrastructure of fully interoperable electronic patient records for medical professionals is political science fiction. Not because it would be technically impossible, but because it is not what doctors and hospitals need. I think we are moving towards regional networking projects in which a hospital and its referring doctors, or several hospitals and a group of doctors, store data in shared electronic medical records. In addition, there will be web-based personal health records (PHR) where patients can store personal medical data permanently and make it accessible to doctors in case it is needed. The communication between electronic patient records for professionals and PHRs has to be standardised, but not the electronic patient records themselves.”

How important is VHitG in the German health IT market today?

Jens Naumann: “All in all we do have 37 members now, up six from 2005 despite heavy consolidation in the industry. We represent all major players in the German market for hospital information systems. We represent most big providers of RIS/PACS, but only 27% of the IT market for private practices. The reason is that the market leader CompuGroup is not member of the VHitG, and that the remaining companies in this sector are too small to afford working in and paying for an association like VHitG.”

For the last four years VHitG has co-organised the ITeG, a large scale health IT fair, together with the organizer Mesago. Now that the parties have split, there is talk about two ITeGs, one in Frankfurt and one in Berlin. What is the future of ITeG in your view?

Jens Naumann: “The ITeG will take place in Berlin from 8 to 10 April 2008. It will be organized by the trade fair organizer ‘Messe Berlin’, and not by Mesago anymore. The reason for the argument was that VHitG wants to make ITeG more of a meeting point for the whole health IT business. This implies strengthening the conference and education part and reducing the overall time for the fair during the three days of the event. Copyright issues concerning the name ‘ITeG’ will be clarified by a court in due course. With its new concept, ITeG will be even more attractive both for visitors and for the companies on the fair.”

So far, ITeG has been very much a German event. Will this change with this new concept?

Jens Naumann: “ITeG is the leading health IT event in Germany now, and we want it to become the leading event in Europe within the next couple of years. We do have most relevant companies in Europe as exhibitors already. And we are considering simultaneous translation of the conference sessions into English, not in 2008, but probably in 2009.”

Can you give a brief overview of how the German health IT market will evolve in the coming decade?

Jens Naumann: “I am convinced that breaking down the barriers between hospitals and private practices is the one big issue in the German health IT business in the years to come. Industry is clearly moving away from specialised solutions for hospitals, private practices, and pharmacies towards integrated e-health solutions. Companies that exclusively focus on one sector won’t be there any more ten years from now.”