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Berlin As part of the electronic patient file for all (ePA for all), health insurance companies will provide all those with statutory health insurance with an electronic patient file from the beginning of 2025, unless they object. This entails a number of rights and obligations for contract doctors and psychotherapists. The German medical journal spoke to Christoph Weinrich, head of the legal department of the National Association of Statutory Health Insurance Physicians (KBV).

For practices, what is the difference between the ePA and the documentation that has already been done in the primary systems?
It is crucial that uploading documents to the EHR does not replace treatment documentation. Doctors and psychotherapists are still obliged by law and professional regulations to record all medically relevant information for the treatment of their patients. However, the ePA as a file kept by the insured will be able to be used as an additional means of communication and information in the future.

Are doctors and psychotherapists obliged to routinely search through a patient’s entire EHR?
No, there is no obligation to search the ePA without reason. The basis of treatment remains the anamnesis and the doctor-patient discussion. If there are indications that the ePA contains medically relevant information, the relevant documents must be taken into account. In this respect, there will be no new liability risks.

Do doctors and psychotherapists have to personally inform patients about the processes surrounding ePA use for every treatment case or ask whether existing data can be viewed?
No, both the documents that practices are required to provide and the documents that must be provided at the request of patients can also be posted on a notice board.

We want to show legally secure but pragmatic ways to use the electronic patient file and provide a practice notice aimed at those insured. If the patient objects, this will be noted accordingly in the treatment documentation.

What should practices pay particular attention to when it comes to uploading documents to the ePA?
In principle, filling out the ePA can also be delegated. The exception is any available results of genetic tests or analyzes within the meaning of the Genetic Diagnostics Act.

Doctors must store such data personally and are only allowed to do so if the patient has given their explicit consent. The consent must be express and in writing or in electronic form and filed in the treatment documentation.

What expectations do the KBV and the statutory health insurance associations (KVen) have of the ePA software modules from the primary system manufacturers?
For us, it is a central requirement that the handling of the ePA does not disrupt the processes in the practices. Integration into everyday care will only work if handling is as simple as possible and the technology runs smoothly. The PVS manufacturers have a duty here. © aha/aerzteblatt.de