JMIR Publications

ABSTRACT

Background:

Nationwide electronic health records (EHRs) are intended to strengthen patient empowerment and improve information continuity in healthcare. In Germany, the electronic patient record (elektronische Patientenakte, ePA) transitioned from an opt-in to an opt-out model in 2025. Although an ePA is now automatically created for all individuals with statutory health insurance, active use remains voluntary and uptake has been limited. Initial survey data suggest that technical complexity and access requirements may hinder engagement, yet little is known about how insured individuals experience the setup and authentication process.

Objective:

This study aimed to explore how insured persons experience the registration and authentication process of the ePA app and to identify barriers that influence successful access.

Methods:

We conducted a qualitative study based on semi-structured interviews with 23 individuals covered by statutory health insurance in Germany who had experience with or had attempted to initiate the ePA registration process. Data were analyzed using Kuckartz’s structured qualitative content analysis. In addition to phase-specific challenges, cross-phase patterns were inductively condensed into higher-order forms of selectivity shaping access to the ePA.

Results:

Participants described the ePA setup not as a single technical step but as a multi-stage process comprising five sequential phases: orientation, technical entry, verification, interruption, and integration. Barriers accumulated across phases and included fragmented app structures, complex multi-step authentication procedures, technical breakdowns, administrative inconsistencies, and prolonged waiting times. Successful completion of the process depended heavily on individual coping resources such as digital competence, persistence, and self-efficacy. Across the material, five interrelated forms of selectivity were identified: cognitive, capability-based, affective, procedural, and technical-infrastructural selectivity. These mechanisms interacted cumulatively, rendering the authentication pathway selectively passable and prone to dropout, even among digitally competent users.

Conclusions:

Access to the opt-out ePA is structured by processual and structural selectivity rather than isolated technical problems. Formal universality does not guarantee effective usability. To prevent the reproduction of digital inequalities, implementation strategies must address cumulative burdens across the entire authentication pathway and shift responsibility from individual user capabilities toward coherent system design and supportive infrastructures. Clinical Trial: https://www.drks.de/search/de/trial/DRKS00037053 identifier DRKS00037053, Registration Date: 05.06.2025