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BMC Health Services Research
Consumer perspectives onthenational
electronic health record andbarriers toits
adoption inGermany: does health policy
require achange incommunication?
Saskia Kröner1* , Björn Schreiweis2 , Veronika Strotbaum3 , Lea Christine Brandl4 ,
Monika Pobiruchin5 and Martin Wiesner5
Abstract
Background The national health record (ePA) was introduced January 1st, 2021 in Germany and is available
to every person insured under statutory health insurance. This study investigated the acceptance and expectations
of the national health record in Germany, focusing on consumer perspectives, expectations, barriers, information
needs, and communication aspects.
Methods An exploratory, observational, cross-sectional online survey was conducted one year after ePA introduc-
tion, followed by descriptive statistical analysis.
Results The top three ePA use cases were medical document collection, simplified data exchange between medical
institutions, and emergency medical information. Adoption barriers included lack of information and access, privacy
concerns, and perceived lack of necessity. Participants that felt informed about the ePA, reported they received infor-
mation primarily from health insurances, the media, and educational or professional sources, mainly through printed
brochures, social media, or via emails. Most participants (86.5%) preferred being informed through conversations, par-
ticularly with health insurance providers (81.5%) and doctors (61.0%). Written information was highly desired (94.5%),
preferably via email or information letters/flyers. However, more than half of the participants (55.6%) reported being
uninformed about the ePA introduction.
Conclusion The study revealed a communication gap between providers and consumers, leading to a low accept-
ance rate of digital health technologies. Comparisons with other countries showed low adoption rates for opt-in
systems. The authors suggest changing communication strategies, given users prefer direct information from doctors
or health insurance companies. Adopting an opt-out system with professional social media and marketing campaigns
could increase nationwide ePA adoption.
Keywords Adoption, Barriers, National electronic health record, Communication, Consumers
*Correspondence:
Saskia Kröner
s.kroener@hs-osnabrueck.de
Full list of author information is available at the end of the article
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Kröneretal. BMC Health Services Research (2025) 25:33
Background
Technological progress drives the introduction of digital
health technologies [1]. In Germany, the digitalization of
the health and care system is intended to enable citizens
to take more self-determined and informed actions [2].
Part of the Ministry of Health’s (BMG) national health-
care strategy is to offer various healthcare applications
and the secure communication of these services via the
so called Telematikinfrastruktur (TI) [2, 3]. e gematik
GmbH as the National Agency for Digital Medicine, that
is responsible to develop, implement and maintain the
TI, it is hold with a 51% stake by the BMG, the remain-
ing shares are distributed among various healthcare
organizations of the self-governing body. erefore, it
was entrusted with the conception of this infrastructure
and integrated applications. One of the most important
applications is the German national health record (EHR),
referred to as “elektronische Patientenakte” (ePA) [2].
e ePA was introduced 1st January 2021 in Germany
and is available to every person insured under statutory
health insurance in Germany, i.e., the predominant form
of health insurance that includes 74.3 million people as
of April 2024 [4] or approx. 87.8% of the total German
population [5]. Healthcare providers and patients can use
it to store personal health data in a shared record vol-
untarily. To this end, they can store documents such as
diagnoses, treatment plans, emergency data, certificates
of vaccination or a declaration of willingness for organ
donation. e consumers decide for themselves which
practice, which pharmacy or which hospital may access
which health data and for how long. Health insurance
funds and statutory health insurers have no access to the
stored medical data. is means that data sovereignty
always lies with the consumer. Integrated into the Ger-
man telematic infrastructure (referred to as “TI”), end-to-
end encryption is provided. erefore, special connector
hardware is required and installed at the health care ser-
vice providers [6].
e rapid introduction of various digital health tech-
nologies and the system configuration, in which each
interest group primarily pursues its own goals, resulted
in their uncoordinated implementation. Beyond this, TI-
applications were initially introduced partly regardless of
their noticeable added value for patients and healthcare
professionals [7, 8]. is also applies to the implemen-
tation of national electronic health records in Germany
[8]. Until the publication of the first national digitiza-
tion strategy in 2023, various strategies and laws existed
for implementing the digitization of the healthcare sys-
tem; standard guidelines and objectives were lacking [8].
erefore, the ePA was not widely used.
At the end of 2023, two years after the launch in Ger-
many, ePA adoption rates in different age groups remain
low: ~6% (70+y) to 16% (40-49y) [9]. e next step in the
strategy published in 2023 was to provide transparent
opt-out solutions for the use of the ePA from 2025 [2].
Opt-out means, that every eligible person has a record
created unless they object to this.
Against this background, the purpose of the study
presented here was to determine the use of the ePA and
identify the barriers and facilitators from the consumer’s
perspective. e study aimed to answer the following
research questions:
– What is the ePA adoption rate in Germany?
– What are the expectations of consumers regarding
the ePA?
– What are the barriers from the consumer’s perspec-
tive?
– Which ePA-related information do citizens receive?
– How should communication and information on the
ePA be conducted?
Related work
Recent studies have shed light on various aspects of elec-
tronic personal health records (ePHRs) and their impact
on patient engagement, data management, and health-
care outcomes. is chapter examines three key studies
that provide valuable insights into patient awareness,
attitudes, and utilization of ePHRs, as well as their poten-
tial benefits and challenges.
Patient awareness andpreferences
Haug etal. [10] conducted a study focusing on the aware-
ness and attitudes towards the electronic patient record
(ePA) among statutory health insurance members in Ger-
many. e study revealed that nearly half of the eligible
respondents were unaware of the ePA’s existence, indicat-
ing a significant gap in public knowledge about this digi-
tal health tool. Among those familiar with the system, a
majority expressed intention to use it in the future, sug-
gesting a positive outlook once awareness is established.
A crucial finding of this study pertains to data transfer
preferences. Patients strongly favored having control over
their health data, with the most popular option being
consent required before each data transfer. is was fol-
lowed by an opt-out system, while automatic data transfer
without restrictions was the least preferred choice. ese
results underscore the importance of patient autonomy
in managing their health information and highlight the
need for increased awareness campaigns about the ePA.
Patient utilization patterns
Damen etal. [11] conducted a scoping review that pro-
vided insights into how patients interact with Personal
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Kröneretal. BMC Health Services Research (2025) 25:33
Electronic Health Records (PEHRs). e study observed
that patients often exhibit passive utilization of their
PEHRs, particularly when dealing with complex and sen-
sitive medical data. is passive approach manifests as
a reluctance to actively generate and manage their own
medical information within the system. is behavior
stems from concerns regarding the validity, applicabil-
ity and confidentiality of patient-generated data. Fur-
thermore, it has been noted that patient-generated and
-managed health data play a crucial role in ensuring the
completeness and currency of medical records, while also
being linked to increased levels of patient engagement
and satisfaction.
Benets andoutcomes ofpatient‑centered digital health
records
Brands et al. [12] conducted a systematic review that
examined the benefits and outcomes of patient-centered
digital health records e review reported high patient
satisfaction with these systems. Feasibility (15/19, 97%)
and acceptability (23/26, 88%) were positively evaluated.
e benefits of patient-centered digital health records
were most frequently reported in health care utiliza-
tion: 77% (10/13) for "use of recommended care ser-
vices". Benefits of patient-reported outcomes were also
mentioned: 70% (7/10) for "disease knowledge", 56%
(13/28) for "patient engagement", 56% (10/18) for "treat-
ment adherence", 53% (10/19) for "self-management
and self-efficacy". Benefits regarding clinical outcomes
were reported: 48% (16/33) for "laboratory parameters"
(including HbA1c and LDL). Yet, beneficial effects on
"health-related quality of life" were seen in only 27%
(4/15) of studies. However, more positive effects were
reported, focusing predominantly on active functions.
Positive effects were less frequently observed for patients
with a high burden of disease and for high-quality stud-
ies. Nevertheless, no unfavorable effects were observed,
suggesting that patient-centered digital health records
have the potential to improve various aspects of patient
care and outcomes.
ese studies collectively highlight the potential of
electronic personal health records to enhance patient
engagement, improve healthcare outcomes, and promote
patient-centered care. However, they also underscore the
need for increased awareness, attention to patient prefer-
ences regarding data control, and strategies to encourage
active utilization of these digital health tools.
Based on the findings presented in the related work
chapter, it is crucial to further investigate the proposed
research questions to address significant gaps in our
understanding of the electronic patient record (ePA)
implementation in Germany and to improve its adoption
and effectiveness.
Methods
We conducted an exploratory, observational, cross-sec-
tional, online questionnaire study to investigate the adop-
tion of and expectations for the ePA.
An interdisciplinary team of experts from the Con-
sumer Health Informatics working group of the German
Association for Medical Informatics, Biometry and Epi-
demiology (GMDS e. V.) developed the online question-
naire. e questionnaire was implemented with SoSci
Survey in version 3.1.06 [13]. It contains multiple choice
questions and scales, which also provides the option “no
answer” if participants chose to not answer them. For the
original German version and the English translation of
the questionnaire, see details in Additional File 1.
e questionnaire was communicated via various chan-
nels: (i) Newsletters of professional associations such as
GMDS e.V. or of the authors’ institutions, (ii) several uni-
versity mailing lists, and (iii) social media posts via the
X/Twitter profile of the working group. Recruitment took
place between 03.11.2021 and 02.03.2022.
e results presented here are descriptive, as we
refrained from formulating a hypothesis.
Questionnaire
e questionnaire consisted of 30 questions in 5 blocks
that summarized key data about adoption, expectations,
barriers, information needs and communication aspects
as well as demographic data about the participants.
Since there was a chance that some participants might
not be familiar with the ePA, there was an informa-
tional text at the beginning of the survey explaining the
key aspects about the record (“At a glance: What is the
ePA?”). With introductory questions, participants were
asked if they know about the ePA and if they are already
using it for themselves (dichotomous questions). ese
questions were necessary requirements to continue
the questionnaire and for inclusion in the subsequent
analysis.
Expectations
Participants were asked what they expect from the ePA in
terms of data privacy, data security, and user-friendliness
as well as the influence of the ePA on their quality of life
and the quality of healthcare ("I expect the ePA to...").
We also asked about accessibility aspects regarding the
creation, registration and use of the ePA ("I think that...).
Statements were rated on a Likert scale from 1 (=no) to 5
(=fully agree).
Moreover, participants were asked to rate functions
according to their usefulness on a Likert scale from 1
(=not useful) to 5 (=useful). ese included features such
as booking tools for doctor’s visits, reminder of appoint-
ments, document collection and data exchange between
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Kröneretal. BMC Health Services Research (2025) 25:33
healthcare providers. In addition, participants could
enter other functionality they found useful or necessary
via an open question format.
Barriers
In the section on barriers and obstacles to use, partici-
pants who indicated that they did not use the ePA were
asked about their reasons. In a half-open question,
answer options were given as well as the possibility to
give further reasons in a free text field. All participants
were asked about their agreement with other statements
about the ePA. Topics included concerns about data pro-
tection and security, as this is a crucial factor for adop-
tion, according to the literature [14].
Information needs
In the survey part on information needs, questions
were asked about how participants were informed (e.g.
informing people, the form of information). Other ques-
tions focused on the individual perception of ePA con-
cepts, and which form and communication channels
were preferred for receiving information.
Communication aspects
To address communication aspects, we asked related
questions about the way of communication and whether
the participants feel involved in the implementation of
the ePA.
Statistical analysis
e descriptive statistical analysis was performed using
IBM SPSS Statistics version 28 [15].
e R package ggplot2 [16] version 3.4.4 was used for
visualizations.
Participants were excluded from the analysis if they
did not answer introductory questions which we used for
further questions about the knowledge of the ePA and
categorization of participants into certain groups e.g. cit-
izens, healthcare professionals and patients and did not
answer any other questions.
Missing values were reported but were not included in
the calculation of the percentages. If filter questions are
used or questions are only presented to certain target
groups, the population changes.
Free text was categorized according to the ‘Framework
of Nonadoption, Abandonment, Scale-up, Spread and
Sustainability’ (NASSS). In 2017, Trisha Greenhalgh etal.
presented the NASSS framework, a model that helps to
explain non-adoption and abandonment of health tech-
nologies by individual users, as well as challenges to the
diffusion and sustainability of technology-based change
processes in health care institutions (scale-up, spread and
sustainability) [17]. e categorization was performed
independently by four researchers. To check the inter-
rater reliability, Fleiss’ Kappa [18] was calculated.
Results
During the accessible period, we observed a total of 2,891
accesses to the questionnaire and 449 questionnaires
were started. We excluded 17 participants as they did not
fully complete the introductory, basic questions. Since
there are numerous aborted questionnaires, we decided
to include previously answered questions from these
samples. erefore, sample sizes are specified that are
smaller than the number of started questionnaires.
Demographics
e demographic data showed – in terms of gender –
that male (42.4%) and female (37.3%) were evenly dis-
tributed. e median age was between 40 and 49 years.
39.4% had an educational level of 6, which meant they
have bachelor’s or master’s degree or equivalent, 16.4%
even had a doctoral degree. 69.7 percent are insured in
a statutory health insurance. Only 18.1% had on average
more than one medical treatment or consultation per
month. Detailed information is presented in Table1.
Four hundred three participants were aware of the ePA,
93 participants used an ePA, 309 did not use it, 30 did not
answer this question (total of N=432 participants).
Expectations
Participants scored 19 use cases or potential functions
of the ePA on a 5-point Likert scale from not useful (1
point) to useful (5 points). 344 participants answered
this question. Participants rank the ePA as a collection of
medical documents (xrays, Maternaty log), vaccination
certificates, etc. as most useful (mean = 4.7, sd = 0.86).
e top 3 scored use cases are (1) medical docu-
ment collection, (2) simplified exchange of patient data
between medical institutions and (3) emergency medical
information (allergies, medication, etc.). Figure1 shows
the use cases described as beneficial by the participants.
e participants were asked to rate their expectations
concerning the ePA from 1 (=no) to 5 (=fully agree); Fig-
ure2 shows the distribution. Overall, expectations were
high. e median is 5 (=fully agree) for accessibility,
user-friendliness, data privacy and increased safety in the
event of accidents or medical emergencies. Expectations
are somewhat lower for the topics of patient safety, qual-
ity of life and improving the quality of life of chronically
ill patients (Md=4, rather yes).
We asked the participants about their specific views ("I
think...”) on using the German ePA. Figure3 shows that
expectations are high. e participants expressed that (a)
their health insurers create the ePA, that (b) training is
offered, (c) access should be possible from home, (d) the
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Table 1 Cohort demographics, n=432
n proportion
[%]
Gender
Female 161 37.3
Male 183 42.4
Gender-diverse 3 0.7
Prefer not to answer 9 2.1
No response 76 17.6
Age
18–29 55 12.7
30–39 66 15.3
40–49 64 14.8
50–59 91 21.1
60–69 42 9.7
70–79 29 6.7
>= 80 6 1.4
Prefer not to answer 3 0.7
No response 76 17.6
Education level (acc. to ISCED 2011, see Additional le2)
Lvl 2 Lower secondary education 24 5.6
Lvl 3 Upper secondary education 67 15.5
Lvl 4 Post-secondary, non-tertiary education 0 0.0
Lvl 5 Short-cycle tertiary education 17 3.9
Lvl 6+7 Bachelor, Master or equivalent 170 39.4
Lvl 8 Doctoral or equivalent 71 16.4
No qualification or prefer not to answer 7 1.6
No response 76 17.6
Occupation
Employed 236 54.6
In Professional training 16 3.7
Retired 48 11.1
Unable to work 5 1.2
Self-employed / freelancer 20 4.6
Civil servant 16 3.7
Other 8 1.9
Prefer not to answer 7 1.6
No response 76 17.6
Medical Professional
Yes 117 27.1
No 315 72.9
Status of Health Insurance
Statutory health insurance 301 69.7
Private health insurance 47 10.9
Prefer not to answer 8 1.9
No response 76 17.6
On average more than one medical treatment or consultation per month
Yes 78 18.1
No 354 81.9
Number of known illnesses
None 131 30.3
1 77 17.8
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Table 1 (continued)
n proportion
[%]
2 61 14.1
3 37 8.6
>=4 34 7.9
Prefer not to answer 16 3.7
No response 76 17.6
Fig. 1 Functional usefulness for 19 ePA use cases (Likert scale: 1–5); n=361
Fig. 2 Expectations regarding the ePA
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Kröneretal. BMC Health Services Research (2025) 25:33
creation of the ePA should take less than 20 minutes and
that (e) the registration process is quick and uncompli-
cated. Security seemed more important than user-friend-
liness. Almost all participants fully agreed that access to
an individual’s health record must be protected against
misuse.
Barriers
ree hundred participants answered this question and
gave a total of 558 answers. As shown in Fig. 4, 40.7%
of participants (122/300) reported that they do not use
the ePA because they lack information about it. 81 par-
ticipants stated the lack of access and 82 concerns about
privacy. 71 participants did not see the necessity to use
the ePA. 53 participants stated that they do not have the
time to use the ePA, 32 reported lack of technical under-
standing and 19 did not use it because of negative reports
or comments in the media. Only two participants stated
that there are language barriers, 96 mentioned other
reasons.
Participants provided free-text entries for “other rea-
sons” why they do not use the ePA. ese entries were
Fig. 3 Views towards using the German ePA
Fig. 4 Reasons of non-use for participants (n=300); multiple answers could be given
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Kröneretal. BMC Health Services Research (2025) 25:33
coded in the next step: ere was a total of 115 codings
in the dimension “Technology”. Most of them were in
the subdimension “material features” (n=59). erefore,
contributions to complexity in this domain resulted first
from the quality characteristics of the technical systems
(e.g. usability, robustness, maintenance efforts). In addi-
tion, there were codings in the sub-dimensions, which
referred to data types (n=13), the knowledge of use
(n=40) and the dissemination of technology (n=3).
ere was a total of 121 codings in the dimension
“Adopter”. Most of them were in the subdimension, which
concerned the role of the patient (n=76). It addressed
the adoption by patients or clients, including acceptance
(hence symbolic meaning and aesthetics) and the work
required by them. Complexity arose from inapplicable
assumptions regarding the actors, such as health literacy
and patient ownership [16]. 45 codings were associated
to the role of employees. A major significance for com-
plexity in this domain addressed the acceptance of the
change, e.g. if the change conflicted with the professional
self-image of the professionals or strongly changes estab-
lished roles and professional practices.
In total 57 codings in the dimension “organization”
were recorded. e domain included contributions to
complexity that arose at the level of the institution(s) of
health care in which the technology is used. Fifty-three of
the codings were assigned to the sub-dimension “Readi-
ness for this technology/change”. ree codings were
assigned to the sub-dimension “Capacity to innovate”
and one coding to the sub-dimension “Nature of adop-
tion/funding decision”.
e dimension “Wider System” comprised 54 cod-
ings, 24 codings concerned the role of policy. In general,
technology-based changes in health care institutions are
of course also highly dependent on the framework condi-
tions of the respective health care system (macro level).
ere were 8 codings in the dimension “Wider System”,
which concerned the role of the regulatory/legal frame-
work. Influences on complexity have legal framework
conditions (e.g. data protection). 16 codings concerned
the role of professional, and six sociocultural perspec-
tives. e socio-cultural framework conditions included,
for example, attitudes of the general population.
Only eight codings were assigned to the dimension
“Condition”. ree codings to the area “Nature of con-
dition or illness”, five to “Comorbidities, sociocultural
influences”.
To assess the extent of the matches, the interrater reli-
ability was calculated via Fleiss’ Kappa. For the coding of
other reasons (for non-use) using the NASSS framework,
a strength of agreement of “slight” (.172) was achieved.
Participants were also asked how well they felt involved
in the introduction of the ePA. For this purpose, the sam-
ple was divided into patients (in treatment more than
once a month on average, n=54), citizens (n=295) and
professionals (n=78).
Figure5 shows the distribution of perceived involve-
ment in the three groups. e median in the special-
ist group is 2, which means that they tend not to feel
involved. e median for the patient group is between
1 and 2, meaning that they also feel little to no involve-
ment. e lowest median (=1) is for the Citizen group,
which means that they do not feel involved at all.
Information Needs
e participants were asked in which form they would
like to be briefed to feel sufficiently well informed. 356
participants answered the question. 308 out of 356
(86.5%) would like to be informed in a conversation. Of
those participants 81.5% (251) said they would like to
have this conversation with the health insurance, 61.0%
(188) mentioned the doctor. Only a few participants
wanted conversation with the employer (20; 6.5%), in
Fig. 5 Involvement in ePA introduction per user group (5-point Likert Scale: 1=no, 5=fully agree)
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Kröneretal. BMC Health Services Research (2025) 25:33
education or training (23; 7.5%), with family members
(16; 5.2%) or with friends/acquaintances (17; 5.5%).
In a free text field the participants stated, that they pre-
ferred to be informed by a data protection officer, IT con-
sultants, independent organizations, via services of the
federal ministry of health (BMG) or by gematik GmbH,
Case managers, Ministry of Health, state education agen-
cies, trained medical professionals at health care provid-
ers (doctor’s office, hospital, etc.), caregivers, through
participants own enquiries or by public media.
326 out of 356 (94,5%) participants would like to be
informed in writing. About two thirds of the participants
(235/326; 72.1%) would like to receive the written infor-
mation via e-mail, 60.1% (196/326) via an information
letter or flyer.
261 out of 356 participants would like to be informed
digitally. Of these, about two thirds (175; 67.0%) say
they would like to be informed via their health insur-
ance application. About one third of the participants (93;
35.6%) via a social media campaign, about a half (124;
47.5%) via a multimedia offer such as videos.
240 out of 356 (67.4%) participants would like to be
informed through traditional media offers such as news-
papers (160; 66.7%), television (143; 59.6%) or radio
(102; 42.5%). Only 87 out of 240 (36.3%) would like to
be informed via podcasts. Further wishes from free text
forms were public awareness campaigns and journals of
health insurances.
Communication aspects
More than half of the participants report that they were
not informed about the introduction of the ePA (240,
55.6%). 118 (27.3%) participants were informed about the
ePA, while 74 (17.1%) did not answer this question (total
of 432 participants).
About one half of the informed participants (60/118,
50.9%) were informed by their social health insurances
about the ePA. 38.1% (45/118) were informed by the
media and 28.0% (33/117) were informed about the ePA
as part of their education or professional qualification. In
contrast only 4.2% (5/118) were informed by their doc-
tors. In the free text field, the participants also mentioned
that they were informed due to a professional back-
ground /study, a health insurance company, specialist
portals or directly via gematik GmbH.
When asked how they were informed, most partici-
pants said they were informed through printed brochures
(44/118, 37.3%), followed by social media (29/118, 24.4%)
and emails (25/118, 21.0%). In addition, participants were
asked how well informed they felt about the introduction
of the ePA, rated on a Likert scale. For this purpose, the
sample was divided into patients (in treatment more than
once a month on average, n=54), citizens (n=301) and
professionals (n=79).
Figure6 depicts the distribution of the perceived level
of information in the three groups. e median value
for all groups is two, which means they felt rather not
informed.
However, the 25th and 75th percentiles revealed some
differences between the groups. At the 25th percentile,
both patients and citizens reported a score of 1.0 (=no),
indicating that at least 25% of respondents in these
groups felt minimally informed. In contrast, profession-
als showed a slightly higher level of perceived informa-
tion at this percentile, with a score of 2.0 (=rather not).
e 75th percentile scores highlighted more pronounced
differences. While citizens maintained a score of 2.0,
patients showed a slight increase to 2.25. Notably, profes-
sionals demonstrated the widest range of responses, with
a 75th percentile score of 4.0 (=rather yes), suggesting
that a quarter of the professionals felt considerably more
informed than the other groups.
Participants were also asked with whom they had spo-
ken to about the ePA. 192 of 432 participants (44.4%)
Fig. 6 Information on ePA introduction per user group (5-point Likert Scale: 1=no, 5=fully agree)
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Kröneretal. BMC Health Services Research (2025) 25:33
responded, 158 of 432 participants (36.6%) stated they
talked but with no group or person that were provided in
the answering options, 82 of 432 did not answer (19.0%).
Around 56% each said that they had spoken to fam-
ily members (109/192) and work colleagues (108/192).
Almost as many (104/192, 54.2%) said acquaintances/
friends. 30.2% mentioned doctors (58/192) and 25.5%
(49/192) the health insurance company. e free text field
also included: Professors/Teachers, Science journalist,
Politics, associations, IT company, Family practice staff
or/and professional societies.
Discussion
e results of the survey showed that the ePA was and
is still not widespread. is is confirmed by a recent sur-
vey in Germany of Kühnel etal. [9]. Our results show that
one year after the introduction of the ePA, 21.5% of our
respondents were using the ePA and 93.3% were aware of
it. Furthermore, they report that 9% of the German popu-
lation use the ePA and 76% have heard of it (as of Decem-
ber 2023 - two years after our survey). is comparatively
high number in our results might stem from a high level
of education of the participants on average, as well as the
recruitment process, which targeted health-related asso-
ciations, study programs, etc. (see Limitations).
De facto non-use in Germany is not necessarily to be
understood as active rejection but is often due to insuf-
ficient knowledge on the part of patients and providers
and the existing legal framework [19]. is is in line with
the observation of this study as only 27.3% of the partici-
pants stated that they had been informed about the ePA.
Furthermore, the results show the request for informa-
tion via channels such as email, social media, newspa-
pers, television, etc.
e top three scored use cases in our study are (1)
medical document collection, (2) easier exchange of
patient data between medical institutions and (3) emer-
gency medical information (allergies, medication, etc.).
Similar functions included in patient health records were
identified in the systematic review by Harahap etal. [20].
e authors found more than 50 studies that reported
use cases comparable to (1) and (2). e management
of emergency medical information seems to be not the
focus of the studies. However, medication and prescrip-
tion management as an “Advanced function” of a patient
health record is reported by numerous systems [20].
Interestingly, already in 2012, Kharrazi etal. performed
an evaluation of nineteen “stand-alone mPHR applica-
tions" and regarded emergency contact information as
one of the most important data elements to be included
in a patient health record [21]. Overall, the expected and
as most-useful perceived use cases by the participants
match the provided functions of the German ePA as well
as many other EHRs and PHRs. One drawback of the
review by Harahap is that it included several approaches
of electronic health records as well as methodologies,
e.g., stakeholder interviews prior launch, conceptual
papers and regional projects.
e features that consumers perceived as useful in this
study surpass those currently offered by the ePA, e.g.,
“Schedule of appointments” and “Reminder for sched-
uled medical appointments”. However, our findings indi-
cate that participants wished for the ePA to become a
central hub that helps them to navigate their patient jour-
ney and complex treatment scenarios. is vision aligns
with a whitepaper from 2020 issued by gematik GmbH
[22]: Providing an infrastructure with the TI as back-
bone with interfaces to third-party apps. In this vision
of a digital healthcare system, an ecosystem of medical
application from primary and secondary market could be
integrated seamlessly. To achieve such a vision, a strong
political will is needed to unite all key stakeholders.
Observing the transformation process of the German
healthcare system, political will seems to be quite selec-
tive. Here, it is worthwhile to compare the introduc-
tion of nation-wide Digital Health Applications (DiGA)
in 2020 with the ePA introduction. DiGAs are certified
and evaluated applications, e.g., smartphone apps, that
can be prescribed like an ordinary drug [23]. Since 2016,
the BMG commissioned evaluations on how to integrate
innovative mobile health applications in routine care, i.e.,
roughly four years were needed to get medical mobile
applications into the complex German healthcare and
reimbursement system. For the ePA and its predecessors,
the design and development phases now span more than
two decades. In view of the DiGAs’ introduction, it can
be concluded that there were more substantial political
efforts for a rapid distribution than currently observed
for the ePA.
Initiatives like Digital Navigators (DN) [24] were estab-
lished to boost DiGA acceptance and usage. e Digi-
Navi study pilots DN in primary care and outpatient
psychiatric services, indicating strong political support
for DiGA. In comparison DiGA implementation appears
more targeted and user-oriented than ePA. While ePA
faces challenges in standardization, security, and user-
friendliness, DiGA sees concrete measures for increasing
acceptance and competence development. ePA imple-
mentation struggles with interoperability and governance
structures. At the same time, it is easier to implement
a "single" application such as a DiGA with low connec-
tion to other Healthcare-IT-Systems to date, than a more
complex product such as the ePA.
In view of the planned implementation of the opt-out
procedure in Germany in 2025, the question arises as to
how communication can accompany a "new start" for the
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Page 11 of 14
Kröneretal. BMC Health Services Research (2025) 25:33
ePA. Various studies have focused on the communicative
elements of ePA use, but most of them focus on com-
munication between doctor and patient in the immedi-
ate treatment context or on the effects of EHR use on
the doctor-patient relationship [25, 26]. To improve ePA
adoption, also a multi-channel approach should be imple-
mented, focusing on clear, comprehensive information,
especially also about beneficiaries and the management
of potential risks of use, disseminated through health
insurance providers, healthcare professionals and vari-
ous media platforms. Special attention should be given to
addressing the current lack of information and ensuring
that all demographic groups are adequately informed.
Limitations
To better contextualize the results in the following com-
parison, further limitations regarding the population
reached should be mentioned. It is possible that the pro-
cedure for recruiting participants led to a selection bias.
In this context, most participants have a high level of
education. is may not be representative of the overall
population. Furthermore, it is possible that mainly people
with a high or very high affinity for information technol-
ogy have answered the questions respectively answered
the questionnaire. Due to the relatively high percentage
of people who have given no information at all on their
state of insurance, it might well be that possibly the per-
centage of privately insured respondents of this study
exceeds the share of the total population. To estimate the
extent of a potential selection bias, the authors tried to
compare participants’ data with the last survey of educa-
tional qualifications by the Federal Statistical Office [27].
Unfortunately, this is not directly possible due to differ-
ent survey methods. Here, a distinction is made between
the highest school-leaving qualification and the highest
vocational qualification, while in the survey both were
integrated into the overall highest educational qualifica-
tion. Nevertheless, as expected, the proportion of people
with higher educational qualifications in the overall pop-
ulation is lower than in the sample reached. e aspect
of ethnic groups and language skills was not part of the
compilation of the sociodemographic data. Here it is
also quite possible, that mainly native German speakers
respectively people with very good German skills have
participated in the survey. is means that representa-
tiveness is not given and language barriers may constitute
a general obstacle regarding the self-determined use of
the ePA, even a migratory background does not per se go
along with a lower digital health literacy [28]. Since there
are different concepts of electronic records in the health-
care system, the authors had in advance integrated a
short explaining text for the participants of the survey to
reach a coherent term understanding. Nonetheless it is of
course possible that against the background of different
experiences with digital health-related applications that
the participants of the survey did not always just follow
the concept of the German ePA that was presented here.
Comparison withprior work
When it comes to the acceptance and increased uptake
of eHealth in Germany, decision-makers, study authors,
etc. often say that patients and service providers need to
be "taken on board” – without explaining this sentence in
more detail. It is therefore worth looking at what other
countries are doing to increase the uptake of ePA. For
reasons of comparability with the results of this survey,
only electronic health records like the nationwide Ger-
man ePA will be discussed in the following paragraphs.
An increasing number of citizens in European and
other countries has access to a personalized health
record, such as the German ePA. However, access and
use (e.g. secondary use in health research) are regulated
differently [29, 30]. For example, countries such as Aus-
tria and the Scandinavian countries chose an opt-out
approach [31]. A study conducted in 2021 on the legal
interpretation of the ePrivacy Directive [32] showed
that the opt-out procedure leads to significantly higher
usage rates. In Austria, for example, 97% of the popula-
tion use an ePA. In Denmark, where ePA has been man-
datory since 2004, almost all General Practitioners (GPs)
and pharmacies, hospitals and specialists use electronic
records [29].
e national personal health record in Australia was
introduced in 2012. e initial adoption of the sys-
tem was considered low with only 21% as of 2017 [33].
After changes in legislation the original opt-in model
was changed to an opt-out model in 2018 to increase the
adoption. e ePA in Germany was also launched as opt-
in and will be transferred to an opt-out model in 2025.
e Australian Digital Health Agency reports on the
Implementation of the My Health Record system in 2019
[34]. ey stated that the communication strategies were
effectively implemented. In 2017, a communication plan
was crafted based on evaluations from earlier partici-
pation trials and additional market research. is plan
involved creating, testing and distributing various infor-
mational materials such as brochures, posters, and vid-
eos targeted at specific audiences. e Australian Digital
Health Agency (ADHA) monitored the reach of these
communications, finding that the average Australian was
exposed to information about My Health Record approx-
imately 38 times during the opt-out period, leading to a
rise in public awareness over time. Additionally, ADHA
conducted educational initiatives for healthcare provid-
ers. ese efforts ensured that every general practice and
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Page 12 of 14
Kröneretal. BMC Health Services Research (2025) 25:33
community pharmacy in Australia had access to edu-
cational resources about My Health Record, which was
reflected in the increased registration and usage of the
system.
Pang and Chang [35] analyzed Social Media posts on
Twitter and suggested communicating with stakeholders
via social media as well. is matches our study’s find-
ings, with over one third of the participants stating they
wanted to be informed via a social media campaign. e
literature research does not provide explicit details on the
methods by which citizens are generally informed about
the existence of a health record. Only about France is it
described that the first information was received from
the social security organization via E-Mail. After that the
physicians constantly hand out flyers to their patients
[36].
Besides the information about the results, there is
follow-up information, which also should be commu-
nicated. Abd-Alrazaq et al. conclude that “promotional
campaigns about functions and features of the system”
should be conducted whereas direct communication
between patient and health care professional could be
one of the most effective channels [37]. e results of our
survey support this: Almost 90% of the participants pre-
ferred face-to-face information.
In addition to the problem of communication regarding
the release of the ePA, we observed barriers in our study.
Yousef etal. [38], also observed some barriers regarding
the personal health record adoption in Saudi Arabia from
the perspectives of healthcare providers (HCP). e top
3 barriers to Nationals Electronic Health Record adop-
tion were lack of patient awareness, patient low literacy
and patient resistance to new technologies. In a qualita-
tive approach three primary themes were identified in
the comments of the survey: general perceptions of the
Nationals Electronic Health Record (positive attitudes,
negative attitudes, additional features), 2) patient engage-
ment as a requirement for the successful implementation
of the Nationals Electronic Health Record and 3) educa-
tion/training of HCPs, patients, and caregivers. When
comparing our results, there is a certain overlap. Barriers
mentioned such as lack of access or time could be inter-
preted as a lack of engagement in the acquisition. A lack
of technical understanding, on the other hand, could be
overcome through the training of patients.
An additional barrier which is stated in our results is
the concern about data protection. 14.7% of the non-users
stated that they have concerns about data protection (top
3 reason for non-use). is is in line with the results of
the national EHR in the UK. e National Health Ser-
vice (NHS) introduced an England-wide ePHRs in 2015.
In the years after launch the adoption remained low with
24.4% in 2018 [37]. In their study based on the unified
theory of acceptance and use of technology (UTAUT
2.0) framework, they found that patients are more likely
to use ePHRs if it is perceived as „very useful and advan-
tageous“ [37]. Moreover, patients are more likely to use
an ePHR if it is secure and maintains data privacy. e
healthcare system in France follows another approach
regarding data-protection. ere the EHR is an optional
and voluntary process for patients, regulated by the Act
of Public Health Code. Patients create and manage their
EHR, accessible online for medical monitoring. Access
rights are stringent, with only attending physicians and
Emergency Medical Services having full access. It could
be expected that there will be further discussion on data
protection and privacy. In Australia, the change to the
opt-out strategy led to “vociferous discussions of the pri-
vacy concerns” [39] and privacy is considered a major
issue in Germany as well.
Conclusion
Given the results of this study, health policy in Germany
requires changes in ePA communication. Low adoption
rates and lack of awareness among the population indi-
cate that existing communication strategies have been
insufficient, as adoption is associated with perception of
benefits (cf. [37, 38]). Consumers expect the ePA to be a
secure, accessible and user-friendly system that facilitates
the collection and exchange of medical information, with
a strong emphasis on data privacy and improved health-
care outcomes. Yet, several barriers hinder ePA adoption.
e primary obstacle is a lack of information. Other sig-
nificant barriers include privacy concerns, lack of access,
perceived lack of necessity, time constraints and insuffi-
cient technical understanding. Further challenges include
technical issues, complexity arising from health literacy
assumptions, and readiness for technological change.
e study also revealed a low level of perceived involve-
ment in the ePA introduction across patients, citizens
and professionals. Most participants reported feeling
uninformed about the ePA, with over half stating they
received no information about its introduction. ose
who were informed primarily received information from
health insurance companies, media sources, or through
their education or professional qualifications. Even with
a sample that is biased towards higher education qualifi-
cations and high IT affinity, this study sheds light on the
early adopters of ePA with their expectations and barriers
they faced in 2021 and 2022. Especially regarding the opt-
out transformation in early 2025, the presented findings
provide valuable ground for future surveys.
An uncoordinated introduction of digital health tech-
nologies leads to a low acceptance of the ePA. e results
of this study show a communication gap between provid-
ers and consumers. However, a comparison with other
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 13 of 14
Kröneretal. BMC Health Services Research (2025) 25:33
countries shows that this is not only a problem of Ger-
man implementation. It appears that other countries with
opt-in procedures have comparable low adoption rates.
One solution to the problem appears to be a change in
communication strategy. Users want direct information
from doctors or health insurance companies. e exam-
ple of the Australian strategy shows that the change to an
opt-out solution in conjunction with a professional social
media and marketing campaign as well as educational
offers could increase the adoption of the ePA.
Abbreviations
BMG German Federal Ministry of Health
DiGA Digital Healthcare Application
eIDAS Regulation on Electronic Identification and Trust Services
ePA Electronic Health Record (German: elektronische Patientenakte)
gematik Gesellschaft für Telematikanwendungen der Gesundheitskarte
GKV Statutory health insurance (German: Gesetzliche
Krankenversicherung)
GP General Practitioner
HCP Health Care Provider
IT Information Technology
NHS National Health Service (UK)
PEHR Personal Electronic Health Record
PHS Public Health Service
SGB German Social Code
TI Telematics Infrastructure
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12913- 024- 12175-6.
Additional file 1. Original Questionnaire (English version). The translated
version of the original questionnaire is provided as a supplemental PDF-
File (ePA-Survey-Questionnaire-english.pdf ).
Additional file 2. Mapping of German Education Levels to International
Standard Classification of Education (ISCED).
Acknowledgments
The authors would like to thank all participants for their time and effort in tak-
ing part in this survey. We would also like to thank all members of the SIG CHI
for their input, especially Silvia Woll.
The authors would like to thank two anonymous reviewers for their construc-
tive comments and suggestions.
Authors’ contributions
MW proposed the initial survey design, and all authors (MW, MP, LB, VS, BS,
and SK) contributed to the conception and design of the survey. Each author
participated in data acquisition. MP, LB, and SK were involved in data curation
and analysis. All authors (MW, MP, LB, VS, BS, and SK) contributed to the inter-
pretation of the data. SK drafted the first version of the manuscript. All authors
(MW, MP, LB, VS, BS, and SK) contributed to the manuscript, reviewed it, and
approved the final version.
Funding
Open Access funding enabled and organized by Projekt DEAL. The authors
received no funding.
Data availability
The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Approval from the institutional review board or equivalent committee(s) was
not obtained, as the online survey represented non-interventional research
with anonymised data that included not specifically patients but citizens.
However, an ethical self-assessment was carried out in accordance with the
recommendations of the German Data Forum (RatSWD) for surveys that do
not contain any questions that are likely to have a negative impact on the par-
ticipants. All relevant ethical standards (Declaration of Helsinki, Code of Ethics
of the German Sociological Association (DGS) and the Professional Association
of German Sociologists (BDS)) were adhered to, and the rights and well-being
of the participants were fully protected. Informed consent was obtained from
all participants. Participation in the survey was voluntary, and all responses
have been analyzed anonymously, ensuring that no reference to individual
participants can be made.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1 Health Informatics Research Group, University AS Osnabrück, Osnabrück,
Germany. 2 Institute for Medical Informatics and Statistics, University Hospital
Schleswig-Holstein and Kiel University, Kiel, Germany. 3 Consumer Health
Informatics special interest group of the German Association for Medical Infor-
matics, Biometry and Epidemiology (GMDS e. V.), Cologne, Germany. 4 Institute
of Telematics, University of Lübeck, Lübeck, Germany. 5 Heilbronn University,
Heilbronn, Germany.
Received: 8 August 2024 Accepted: 24 December 2024
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