>> Various studies show that Germany has a lot of catching up to do when it comes to digitalization; in a recent survey from 2018, two thirds of the participants even classified the healthcare industry as poorly digitalized (Roland Berger 2018). In an international comparison of “Smart Health Systems” by the Bertelsmann Foundation, Germany is only in 16th place out of 17 countries, ahead of Poland at the bottom, with Estonia, Canada, Denmark, Israel and Spain taking the top places. Some of the examples of how digital technologies are already being integrated into everyday healthcare there: examination results, medication plans or vaccination data can be viewed and managed online, prescriptions are transmitted digitally and billed fully electronically to the health insurance company, remote diagnoses and remote treatments are offered via video or even intelligent algorithms for the prediction and prevention of diseases as well as for research and development. The basis is the data available on the basis of the electronic patient files (Kostera/Tranberend 2018). E-Estonia is a pioneer in digitization. As early as 2000, a kind of mediation platform was put into operation in Estonia, to which almost all official databases and, in 2008, health data were gradually connected. In addition to your personal pin code, you need a registered mobile phone to identify yourself on this platform. Possible misuse is controlled by a data protection authority and personal transparency regarding access data (Balzter 2018). The advantages are obvious: Because all medical diagnoses, laboratory values and images are stored in a database, double examinations can be avoided. Every doctor can access online, so the patient can freely choose the practice and the corresponding doctor already has his data. What are the general conditions in Germany? The so-called “E-Health Act” was passed by the Bundestag more than three years ago as a law for secure digital communication and applications in the healthcare system. However, the implementation of the applications based on the electronic health card (eGK) is running more slowly than planned.
On March 14, 2019, the Bundestag passed the Appointment Service and Care Act, which accelerates the rollout of the telematics infrastructure (TI) and makes telemedical services possible. All insured persons should have access to their files via their mobile devices, while all statutory health insurance companies will be obliged to provide their insured persons with a digital file by 2021. It is also intended to regulate the access of digital applications to the primary healthcare market and questions regarding technical and semantic interoperability (bvitg 2018). The first healthcare market includes the area of “classic” healthcare, which is largely financed by statutory health insurance (GKV), private health insurance (PKV) and subsidies together with nursing care insurance. Due to the lack of a uniform solution, some health insurance companies have already started to introduce individual health records for their insured persons with different collaborations and app offers, including Allianz, DAK, DKV, Central, Signal Iduna, Techniker Krankenkasse (TK) and Union Krankenversicherung / Bavarian Civil Service Health Insurance Fund (UKV / BK). However, critics fear a patchwork of different offers without a common standard (Fuest 2018).

While healthcare costs rise every year, the use of digital technologies in the German healthcare system could save up to 34 billion euros annually. Paperless data, online interaction and automation of work processes have the greatest economic benefit (McKinsey 2018). When automating processes and in administration, organizations can increase their efficiency with smart technologies by an estimated 15 to 20 percent by 2021 if they use digital applications for, among other things, business process optimization or the development of medical products (PwC 2018). Artificial intelligence (AI) is considered to have great potential for impact. The term “artificial intelligence” was first used in 1955 by the American computer scientist John McCarthy. Today, AI includes components of algorithm-based “machine learning”, with which automated processes and analyzes can be achieved based on the evaluation and correlation of raw data (weak AI), as well as the recognition and interpretation of causal relationships and learning from scenarios and behavioral adaptation (strong AI) (Halper 2017). How the use of AI can help is outlined in two example application scenarios.

Comprehensive data analysis is required to develop products or assess risks. With a newly implemented analysis platform, a “Distributed File System” for faster data analysis, unstructured amounts of data are evaluated very flexibly in real time across various servers and databases. It is also about recognizing progressions and behavioral patterns in data analysis. The Versicherungskammer is one of the first insurers to use this technology (Spieleder 2017). Further advantages of AI can be achieved, among other things, in complex hospital bill auditing. A medium-sized German insurer with more than 1.5 million members receives up to 700,000 applications for reimbursement from hospitals every year. Cognitive systems can help to reliably filter out and process incorrect invoices. If AI were to achieve just a one percent increase in invoice corrections in this context, this would equate to a savings potential of 500 million euros for German health insurance companies (McKinsey 2017).

As part of improving operational efficiency and performance in hospitals at departmental and organizational levels, AI's ability to handle large amounts of data can help management optimize performance and productivity. In this way, existing resources can be better utilized, saving time and money. In radiology, AI can be used, for example, to optimize referral management, appointment scheduling and preparation of examinations, as well as the results themselves. “The AI-assisted segmentation of lesions and organs can now be carried out fully automatically” and takes 2 minutes with the computer compared to 2 hours for the radiologist, whose role should not be replaced but strengthened (Seo 2018). This can improve patient satisfaction and enable effective and efficient use of all available facilities. With AI-enabled solutions, large amounts of clinical data can be combined to gain a holistic view of the patient. This supports the clinic staff in making decisions and optimizes the success of the treatment. The first AI-controlled hospital is already being implemented in Great Britain through a cooperation between GE and the Bradford Teaching Hospitals. A Command Center, which operates like an air traffic control command center, provides a detailed, real-time overview of the 800-bed hospital and supports employees in their decisions on how to best manage patient care. The aim is not only to support efficiency and effectiveness in terms of patient volume and care, but also to reduce waiting times, improve the patient experience and reduce pressure on clinical staff (GE 2019).

The discussion of “market pull” versus “technology push” has a long tradition in business innovation research (see, for example, Cooper/Kleinschmidt 1991, Pfeiffer 1992). “Technology Push” describes a situation in which a new technology is the driver for innovative products or problem solutions on the market. In extreme cases, new technology concepts can even create their own markets if they result in radical product or process innovations. In contrast, the "market pull" concept assumes that product or process innovations have their origin in (latent) unsatisfied customer needs on the market. "Market Pull" thus takes knowledge of potentially new areas of need as a starting point for innovation strategies. Clayton Christensen, the founder of modern disruption research, developed this further in his book "Competing against Luck" in a framework that he calls the "jobs-to-be-done" approach. A company that wants to be successful must not think in narrow product categories, but in "tasks that have to be fulfilled". Customers buy products to make progress toward solving a problem in their life (Christensen 2016). In the context of digitization in the service economy, it is precisely this "service innovation" that is gaining in importance. Service innovation starts directly with customer benefit and creates new ways for service types and provision. Innovation in services is an interaction of service concepts, service delivery systems, customer interfaces and technologies (den Hertog 2000). The aim is to develop offers that create a high level of utility for the customer and increase their willingness to pay in this regard, while at the same time supporting customer satisfaction and thus factors such as customer loyalty (returning customers) and recommendation rates.
The healthcare industry offers a wide field here that still offers a lot of future potential. Their primary tasks are to prevent, diagnose, or cure disease. It is therefore understandable that the majority of stakeholders in the healthcare industry are focused on how to provide better products and services to achieve these three goals. In addition, there are a variety of other “jobs-to-be-done” that people decide about when it comes to their health and who they “engage” with them. For several years, there has been a trend that both doctors and patients research symptom and disease-related information using web search engines. In “jobs-to-be-done” terminology, these are so-called “underserved customers” who react to an unsatisfactory offer in this area. According to a study by the Bertelsmann Foundation, 58 percent of patients asked “Dr. Google” for relevant information. 52 percent of those surveyed stated that they were satisfied with the results of their internet research (Bertelsmann Stiftung 2018).

The aim of new technologies should be to enable better care in the healthcare system through preventative measures through careful use of contributions and resources. People with their individual and collective benefit components should always be the focus when using AI, then the potential outweighs the possible risks. The collective benefit is aimed at gaining medical knowledge in the healthcare system through digital progress: for example, in improving cancer treatments through the evaluation of a large amount of anonymized patient data; The individual benefit is achieved in improving the medical care of customers, e.g. special therapy in individual cases. The corresponding protection of individuals and their rights (e.g. with regard to data sovereignty) is anchored in the German and European value system.
Opinions differ as to whether one should speak of patients, insured persons or (healthcare) customers in the healthcare system. The customer takes on different roles: in the context of the doctor-patient relationship, that of the patient or, in relation to billing for services, that of the insured person. If you focus on the customer's perspective, this means that the “demander” of healthcare services has sovereignty and has to make the right decision in the face of competition. This implies that digital networking in the healthcare industry should generate customer benefits on the basis of which corresponding services are provided. “Customer Centricity” or radical customer orientation is a term that is becoming even more important in the digital world, because customers no longer only interact with providers physically, but also via digital media. Ultimately, the goal is to make healthcare not only more efficient through digitalization, but also better, more comfortable, simpler and less time-consuming, thereby creating greater benefits for all stakeholders. Individual benefits arise, for example, from better care in rural areas through appropriate telemedicine offers or the creation of communities for patients with the same clinical pictures. Collective benefit dimensions can be served by analyzing a large number of data for research purposes.
In 2018, the Versicherungskammer group conducted a survey of 600 insured people to determine customer expectations of digital health management. The majority (77 percent) view digitalization and the data issue positively; 80 percent would provide their healthcare provider with information about age, height and weight; half of those surveyed would share information about physical complaints, laboratory values or previous treatments. The survey also made it clear that customers want additional services, be it for fitness and prevention (60 percent), reminder functions for doctor's visits (50 percent), paperless processing of prescriptions or invoices (a third) or an online chat with doctors (a quarter) wish. The ePortal “My Health” has now been launched by leading private health insurance companies, which includes these topics (Versicherungskammer 2018). The customer has the opportunity to store all health data digitally via a document safe and in an emergency file. The electronic exchange of documents between service providers, electronic invoice management and functions for individual health management (such as medication plans, appointment management, preventative care tips) complement the digital offering. The underlying data management concept is based on a solution that automatically transfers the data into the file, has a corresponding connection to the most widely used doctor's software on the market (CompuGroup Medical SE) and can be connected to the gematik telematics infrastructure.
The need for more and comprehensive information, but also the supply of individual data on prevention such as fitness, healthy nutrition, stress levels or sleep efficiency, has been constantly rekindled since the advent of smart, mobile devices. “Wearables”, portable devices such as smartwatches, data glasses or fitness bracelets offer the possibility of measuring vital functions such as blood pressure as well as the behavior and influence of environmental factors anytime and anywhere. Users independently collect behavioral data via sensors, which are becoming cheaper and smaller all the time. Although critics see potential for optimization (particularly in terms of interference signals, energy efficiency, performance), the estimates for market growth are nevertheless unbroken: According to IDC, the market for wearables is expected to grow from 113.2 million units in 2017 to 222 with an annual growth rate of 18.4% .3 million in 2021 (IDC 2018). Sales in Germany are also growing steadily and will amount to around EUR 375 million this year.
Insurers are also taking up the topic, such as Generali's Vitality program, the aim of which is to motivate customers to live a health-conscious life on the basis of occupational disability and term life insurance and to reward their progress. The UKV/BK has developed a portfolio of digital health services for its customers that serve different medical conditions but also life situations, such as travel advice, tele-consultation, tinnitus app, desire to have children, etc
The start-up scene has also discovered the market for (purely) digital insurance offers: ONE Insurance offers an app that evaluates various parameters (such as working hours, sleep, exercise, location). Modular short-term insurance policies are offered based on individual lifestyles. It remains to be seen which provider can best do the “job” for the customer – but also do it successfully in the long term. In any case, the spectrum of digital innovative services is very large and offers a lot of potential from administration, health information, appointment and emergency call functions to support for a wide range of illnesses and therapies (e.g. medication management) through apps or online advice for statutory and private insurance companies . Figure 1 shows what such an ecosystem could look like.
The trend towards prevention and the possibilities of digitalization suggest a reversal from the traditional path in the medical treatment chain (presence of an illness, diagnosis and therapy): through appropriate early warning systems (e.g. via wearables), the first signs of possible weak points can be identified, which can be addressed through targeted prevention e.g. can be counteracted with a combination of diet, exercise, medication, etc. Holistic considerations involving evidence-based healing methods are increasingly coming into focus, alongside professional excellence in special disciplines and other actors (Grönemeyer 2018). While platform-based business models and corresponding ecosystems in the healthcare system are already being set up in the USA due to different framework conditions, in this country we are struggling with the difficulties of cross-sector networking. Apple has been expanding its healthcare offering for years, starting with wearables, health apps, health records, health kits and ECGs. It's not just about new products or features, but also about connecting researchers with potential patients. One of the first examples is the Apple Heart study, currently being conducted in collaboration with Stanford Medicine, which compares Apple Watch's ability to detect atrial fibrillation to standard methods. The study recruited more than 400,000 participants via their iPhone (Advisory Board 2019). Better health care is the trend: In February 2019, the starting signal was given for the “Global Health Hub Germany”, which, with 200 partners worldwide, aims to combat diseases such as tropical diseases and cancer.
However, there appear to be factors in Germany that hinder the diffusion of digital technologies in healthcare despite their promise of benefits. The inconsistent regulation of various health systems (separation between service providers, service recipients and payers) as well as financing regulations with sometimes very different incentive systems are seen as a major challenge for the national and international scaling of innovations in the area of e-health and health IT, which leads to: that stable, change-resistant structures are promoted (see Gersch/Wessel 2019).
The advantages for the stakeholders (insured persons, insurers, service providers) are clear. The ability of the various actors to access a common database increases health knowledge, makes disease prevention possible, avoids double examinations, increases transparency and quality, and utilizes the opportunities to increase efficiency and reduce costs. However, this only works on the basis of an electronic patient file, which there is no way around. Of course, based on protected data that is activated accordingly by the patient.
There are currently four consortia in the German market that offer an e-health solution. Most of the solutions were introduced in 2018. The first consortium (IBM, Techniker Krankenkasse, Central, DKV, Signal Iduna) serves the topic of "electronic health records". The main goal here is to encrypt patient data and store the data in a so-called TKSafe. Access is only possible via the insured person and their smartphone key. The second operator, Vivy GmbH, also has a large number of partners behind it and launched its offer to manage your own health records via an app in autumn 2018 with 16 private and statutory health insurers (including Allianz, Gothaer, Barmenia, SDK, Wechselkassen). However, the start-up has already had to take criticism from IT circles for possible weak points. As the third consortium, the AOK health network started its offer at the end of January 2019 with the support of sigeso GmbH. The operators advertise with the three value propositions availability and security of the data as well as speed in data access. The fourth consortium consists of the market leaders in private health insurance (VKB, AXA, Debeka, HuK), who bundle their services in Meine-Gesundheit-Services GmbH via the ePortal “My Health”. The goals are simple and secure digital networking of insured persons, service providers, billing service providers and private health insurers. The underlying philosophy is based on transparency and patient autonomy. The services are available online and mobile. This concept could serve as a blueprint for networking the various stakeholders in the healthcare system.

The examples shown not only provide insight into the immense potential of the healthcare industry through digitalization, they also show the need for action to quickly implement the necessary IT infrastructure and connectivity for all stakeholders. The monitoring report from “Wirtschaft DIGITAL 2018” shows the worst value for the German healthcare industry with 37 out of 100 possible points, which does not change in the forecast until 2023 (BMWi 2018). At the same time, due to the digital revolution, we are experiencing the most rapid technological developments of modern times in an unprecedented dynamic that affects all areas of life. Other countries have reacted and created corresponding requirements and standards with appropriate provisions for data protection and security. Successful countries are characterized by a triad of effective strategy, political leadership and coordinating national institutions (Kostera/Tranberend 2018).
What does this mean for a “German way”? On the one hand, it is about motivating the stakeholders to participate by creating added value. Ultimately, they are just as cost- and benefit-oriented as their customers. On the other hand, it is about specifying a legal framework with a clear schedule: All the prerequisites for this are laid out in the E-Health Act: modern insured master data management, emergency data, electronic doctor's letter and uniform medication plan, telematics infrastructure, ensuring interoperability to improve communication between different IT systems in healthcare and the promotion of telemedicine services (BMG 2019b). The goal should be to build and implement a competitive system. This includes the further expansion of TI as well as an open architecture and corresponding standards to enable interoperability between the actors. Corresponding examples are already available as shown above. The best way to shape digital change is to take pragmatic steps and an agile approach – based on the expected benefits for the healthcare system and (healthcare) customers. <<