Medication infrastructure development in Germany

Klein S, Schellhammer S

In principle, the advantages of the digital transformation of the German healthcare system have been recognized by stakeholders and policy-makers. The need to move forward has been emphasized by governmental and representative bodies. Funding has been allocated to finance pilot projects and infrastructure development. The electronic health card has been and continues to be the flagship of Ger-man ehealth initiatives. Its vision is nothing less than to replace most of the manual, paper-based communication processes by secure, digital pathways. Thereby, the initiative aims for providing a nationwide infrastructure on which in the future numerous applications can be build. It is essentially conceived as the entry ticket into the German healthcare system for every health insurance benefi-ciary. Yet, so far, the development of the ehealth card in Germany is characterized by delays and significant reductions in the functional scope compared to the original plans. For instance, electronic prescriptions are not any more considered as a priority application. While the government pushes the project further, it re-mains uncertain when and in what form the first applications will materialize. Some argue that the “project's sheer size, scale and complexity” is a major cause for its current state (Drews {&} Schirmer, 2015 p.12). An iterative approach combined with a more balanced economic distribution of costs and benefits is suggested as a more promising way (ibid.) While we do not deny that such argu-ments are worth to consider, we would like to suggest the notion of “installed base of opposition” in order to make sense of the difficulties plaguing German ehealth initiatives. We have developed and used this concept to trace the devel-opment of a rather focused, albeit scalable ehealth project over the last 10 years. The clear focus of the initiative on medication management for polypharmacy patients not only implies significantly fewer stakeholders (patients, doctors, nursing homes, pharmacies) but also allows for a tangible definition of economic benefits as well as improvements to quality of care. The initiative aims to im-prove medication compliance for polypharmacy patients by providing patient specific medication packs functioning as dose administration aids, called auto-mated drug (or dose) dispensing (ADD). The involved work process is not entire-ly new but close to the existing practice of blistering pharmacies or blister cen-tres. Especially nursing or care homes and polypharmacy home care patients have been targeted as customers. The initiative aims to automate and informate this process to achieve economies of scale and to reduce errors due to manual blistering. Ideally, the weekly production of individualized medication packs would be built on key components of a general information infrastructure such as e-prescriptions, consolidated medication plans, and electronic communication be-tween doctors, pharmacists, ADD operators and health insurance providers in or-der to be able to operate most efficiently. Thus, ADD would benefit from and nicely tie into an existing information infrastructure like the one envisioned by the electronic health card, but it may very well function without such a basis. In this chapter we will show that this well-focused initiative suffered the same fate as the wider electronic prescription in Germany: It does not feature anymore in the discourse of ehealth applications. In our analysis, we were struck by the lack of an open and substantive discourse among the involved stakeholders. Giv-en the cooperatist and consensus oriented governance of the German health care system, a resistance that ranges from a lack of open discourse to outright block-ade is disturbing. Therefore, we come to the conclusion that the slow and cum-bersome progress of infrastructure development in the German healthcare sector can be explained by the existence of an installed base of opposition. This inter-pretation does not bode well for the latest attempt by the government to jumpstart the digital transformation of the German health care sector.

Publication type
Research article (book contribution)

Peer reviewed

Publication status


Book title
Information Infrastructures within European Health Care - Working with the Installed Base

Aanestad M, Grisot M, Hanseth O, Vassilakopoulou P

Pages range

Title of series
Health Informatics

Springer International Publishing




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