13. October 2023 By Sabine Fischer
Electronic patient record – the opt-out procedure and opportunities available in the private health insurance sector
The German government passed a bill to increase the pace of digitalisation in the health care system on 9 August 2023. This bill includes the opt-out procedure for the electronic patient record, which comes into effect from early 2025 for individuals covered by the statutory health plan, and further updates to e-prescription (eRezept), which will be mandatory for this group starting in 2024. As this relates to the electronic patient record, this means that millions of files will have to be created at one time and information subsequently added to them after that. Only statutory health insurers are required to offer the electronic patient record; this remains optional for private health insurance providers. However, if a private insurer opts to offer the electronic patient record option, this must also be done in accordance with the opt-out procedure.
Other goals include making digital health applications more user-friendly for the provision of care and opening the possibility for digital care processes in structured treatment programmes.
Progress continues to be made in digitalising the health care system. For private health insurers, this not only means the introduction of the electronic patient record as well as taking steps to move forward with the transition to becoming health managers for policyholders. It also entails the digitalisation of further internal work processes. If the latter is not done, there will be interruptions in the process flow along with hefty additional costs.
What is the situation at the moment?
Studies on digitalisation of the health care system show time and again that digitalisation is a topic that stakeholders are now aware of. But there are still many challenges for everyone involved. As we go forward, we will now focus primarily on private health insurers. At these companies there are disruptions to many processes made necessary in order to carry out manual steps. Along with that, the results are stored on paper instead of in electronic documents. The electronic patient record has been put on the back burner at most private health insurers. That is unfortunate since it could be a platform for policyholders to manage their health if used correctly.
The apps most private health insurers offer allow users to view their policies, submit claims for benefits and send or receive e-mails. Policy changes, features designed to provide a clear view of services, a place to store invoices and digital documents are typically not available. Other services such as health apps are offered exclusively via portals, that is, not from a single provider.
Deloitte study: Future of private health insurance (2022)
‘In order to compete in a marketplace where interfaces and processes are increasingly digital, where customer are growing more demanding and where there is an increasing shortage of skilled workers, the majority of health insurers are focusing on developing customer interfaces and initiatives to optimise the processing of benefits.’
Testimonial from a privately insured policyholder
I use the app provided by my insurance company, where I can view my policies, receive e-mails and submit claims for benefits. I get some information on policy changes and checks in paper form and some in electronic form. But what happens if you want to reply via the app? That is simply not possible. The information provided in electronic form is first sent in a physical letter and then attached as a PDF. This letter includes a QR code or the enclosed questionnaire. And the QR code cannot be read; I would have to print it out first. Plus, the questionnaire is not there of course.
I wanted to cancel a policy change I was sent by post for my daughter when she was set to complete her studies because she decided to pursue a master’s degree. I phoned AXA who told me to use the student portal, which is the only way the private health insurer could send the university digital health insurance certificates. If not, it would not be able to send files in digital format. I asked them twice to make sure I had understood correctly that AXA does not send digital health insurance certificates. They confirmed that that is indeed the case. Once I was on the portal, I could not figure out where I could enter my request. I now tried to send an e-mail via the app outlining the situation. I will likely have to call them again in the near future.
So much for digitalisation at my private health insurer. There is a lot that could be done better, that much is clear.
Where do the main challenges lie?
Intelligent input management – technologies that are already obsolete today
Bills from medical practitioners or facilities, invoices for medication or drugs and hospital bills are sent by post to the private health insurer. Or else they are submitted using their app as a PDF. With input management, an attempt is made to generate data from this and use this directly in the follow-up process in a system used to process benefits. The technologies in use are now outdated. Manual follow-up work is required, and there are disruptions to the process flow. Dark processing is only done in a small number of cases. As a result, backlogs build up and policyholders have to call to resolve any issues they may be having. Processes that were created many years ago no longer meet today’s needs. Nothing has been done to bring them up with the times. But users today have different requirements.
It is now possible to read data from a wide variety of invoice formats and process it automatically. Artificial intelligence can provide a critical advantage here.
Process as seen from the user’s perspective – the focus is different today
In the past, processes were often developed from a system perspective. The focus was not on the user, whether that be the case worker or the policyholder. When apps are developed nowadays, the user takes centre stage. Taking the end user’s perspective, it is much easier to respond to requirements and design processes. Of course, this also applies to caseworkers.
Customer journeys that are seen from their perspective open up other points of view and influence internal processes. Customer needs have evolved, and this must be reflected in what a private health insurance company offers its policyholders. Today, policyholders expect their claim to be settled quickly and transparently. Invoices for inpatient stays are already highly automated. This has not yet expanded to cover invoices for prescriptions, drugs, outpatient visits to the doctor, claims for daily sickness benefits as well as treatment and cost plans. We have seen little improvement in processing times and transparency. Through greater automation and increased interoperability, new features can be added to the policyholder app to meet their current expectations. Open interfaces also make it possible to integrate rehabilitation or preventative care apps, services that today are usually only available via a web portal.
Regulatory and data protection hurdles – high costs and a lack of transparency
The standards established by lawmakers and by the EU, also in terms of data protection, are broad and not always clear. Guidelines are often given that are not practical. The current electronic ID (eID) solution makes it difficult to renew one’s ID every six months. In the real world, this is simply not acceptable. A user-friendlier solution is therefore now in the works. However, this requires an amendment to the law, which will take time. For insurers, the question is whether to start out with a temporary solution or wait to launch the final product. This means that all other requirements regarding the eID, such as the introduction of the electronic patient record, are also being put on hold.
It is also possible that there may once again be new requirements, meaning that implementation will be postponed further and further into the future, even if an interim solution is rolled out to set the process in motion. The lack of transparency as well as the possibility that legal regulations may be open to interpretation create uncertainty. The solutions that have been developed significantly increase the implementation costs and practicality for applications.
A private health insurance company has to take a good hard look at these issues. Starting the process early gives you a broader perspective and can lay the foundation for future solutions. It is important to consider every aspect, if necessary with the help of experts from different fields.
Outlook
Policyholders expect services from private health insurance that allow many things to be done without having to contact the company and services that help them keep healthy. The electronic health record is one such service. It can serve as the basis for personalised health services if the policyholder so chooses. Promoting better health can save the private health insurer money in benefit management. Services that expand the self-service options for policyholders enable the insurer to mitigate staffing shortages at service centres.
In order to provide these services, they first need to lay the groundwork. This means they have to roll out new technologies and digitalise all internal processes, which are both necessary in order to offer a self-service option to policyholders and to reduce the workload of in-house staff.
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