The Role of the Installed Base in Information Exchange Among General Practitioners in Germany: Mixed Methods Study

Digitalization is steadily advancing on a global scale, exerting a profound influence on health care systems. To facilitate acceptance of the digital transformation, guiding principles emphasize the need for digital health structures to be person-centered and promote high-quality care. This paper examines the implementation challenges within the German health care system, with a particular focus on how change initiatives engage with existing infrastructures and organizational modes of health care delivery. This approach provides a framework for analyzing how established infrastructure determines new developments while also highlighting the procedural dynamics of change and the integration of innovations within existing information infrastructures. These established infrastructures are referred to as the installed base.

The aim of the study is to examine the installed base encountered by the digital transformation within the German health care system by investigating information exchange practices among general practitioners (GPs) and their communication with other health care actors.

A mixed methods study including a quantitative survey and semistructured qualitative interviews was conducted. The study sample consisted of all publicly accessible GP practices (N=1348) situated in the state of Brandenburg, Germany. The survey captured demographic data, communication practices, and perceived barriers to digitalization. The interviews explored experiences with digital applications. Quantitative data were analyzed using R (R Foundation for Statistical Computing), and qualitative data were managed and analyzed in MAXQDA (VERBI Software GmbH) through content analysis.

A total of 250 questionnaires (response rate 18.5%) and 10 interviews with GPs were included in the analysis. GPs primarily use the telephone (n=138, 55.2%, SD 24.64), fax (n=109, 43.9%, SD 25.40), or post (n=50, 20.2%, SD 9.46) to exchange information. Newer digital communication channels such as messenger applications (n=2, 0.8%, SD 0.72) and Communication in the Medical Sector (n=1, 0.5%, SD 0.97) play a minor role. We identified three intertwined clusters displaying diverse barriers to the digitalization of GPs' communication practices: (1) incompatibility issues and technical immaturity, (2) lack of knowledge and technical requirements, and (3) additional technical, financial, and time-related burdens. These barriers were perceived as significant deterrents to the adoption of digital tools, with older GPs more reliant on analog systems and more likely to view digitalization as a source of frustration.

Newly established communication channels in the German health care system compete with the existing information infrastructure, which is deeply integrated into GPs' practice routines and care processes. However, this installed base has been largely overlooked in digital transformation initiatives. While newer channels hold potential, they often malfunction and are incompatible with long-established, individualized GP workflows. Addressing these issues rather than imposing coercive measures is crucial for increasing adoption. Incorporating health care providers' perspectives and aligning new channels with established routines can prevent frustration and facilitate a smoother digital transformation.