German smartcard rollout brought forward

Germatik, the German eHealth body

In a surprise move, the German health IT agency Gematik has accelerated the schedule of the German national smartcard project to April 2008.

The nationwide rollout of smartcards for all citizens will now start in the second quarter of 2008. “It could easily be finished by the end of 2009”, says Michael Martinet, head of IT at Germany’s second largest health insurance company ‘DAK’.

The decision was taken by the board of directors of Gematik earlier this week. It was not made public until yesterday, though, when state secretary Klaus-Theo Schröder of the national ministry of health announced the new accelerated timetable.

Among the directors of the Gematik are the heads of two medical associations, the head of the national hospital association ‘DKG’, and the heads of the associations of insurance companies.

The German smartcard project is ultimately planned as an online system. Patients will go to their doctor and identify themselves with their smartcard, the ”elektronische Gesundheitskarte’ (electronic health insurance card).

The doctor will then be able to store electronic prescriptions, personal medical data, referrals and discharge letters within a server-based network. To do so, he will use a second smartcard, the “health professional card”.

While this is the vision, reality has looked paler so far. In seven pilot regions, smartcards are used by a maximum of 10,000 citizens each, but only in an offline mode so far. The only thing the doctors can do to date is store some emergency data and electronic prescriptions directly on the smartcard chip. In fact, this has not even been done regularly so far, because of delays with the health professional cards.

The idea, now, seems to be to install a nationwide offline-system first and then to upgrade it step by step.

“A number of health insurance companies are currently working on the details of the future online system. By early 2008, we will be able to guarantee that the smartcard technology is mature, so that we can go for a roll-out”, Martinet told E-Health Europe.

This maturity of the smartcard technology is seen as crucial, because health insurance companies do not want to have to replace the smartcards once they have been issued .

In public, both the leading bodies of medical doctors and key members of the health insurance system endorse the move: “For the doctors, starting with an offline-system will guarantee a smooth transition from paper-based documentation to the digital age”, says Roland Stahl, a spokesman of the “Kassenärztliche Bundesvereinigung”, the powerful head association of medical doctors in private practice.

And Michael Martinet of ‘DAK’ says that his insurance company, at least, is prepared to start early and actually has advocated doing so for a couple of months.

Things look different below the surface, though. The very fact that the Gematik has taken the decision but has not made it public itself can be seen as an indicator that this was certainly not a voluntary move. “The ministry of health has put severe pressure on the Gematik and threatened to go the legal way in case they do not go along with it”, a spokesman of a leading organization of the German health system told E-Health Europe, who asked to remain anonymous.

There are two likely reasons why the ministry of health decided that it might be appropriate to speed things up once again. The first one is an increasing resistance among medical doctors. The recent “Ärztetag” in June, the ‘parliament of German doctors’, has decided to make health IT one of the big topics of next year’s annual political conference. This move is likely to increase scepticism even further. By announcing the start of the nationwide rollout, the ministry of health obviously hopes to head of criticism and deliver facts on the ground.

The second reason is that the government has a promise to keep: Klaus-Theo Schröder has once again repeated that he expects the costs for the German smartcard project not to exceed Euros 1.6 bn. This number is low by international standards, because electronic medical records have never been part of the calculation.

But by starting the roll-out early in an offline-stage and without any EMRs, the government will be able to claim that the projected budget has been met and that insurance premiums will not have to go up for the digitalization of the health system.

However, before the roll-out can start, a number of thorny issues have to be solved. In particular, it is unclear who will pay for the new smartcard readers and software updates in practically all 120,000 or so doctor’s offices in Germany.

“It has always been our position that this money will not be paid for by the doctors”, Stahl told E-Health Europe. It remains to be seen whether politicians and health insurance companies share this view.