The ePatient Survey is one of the most comprehensive online surveys in the German-speaking region and has been conducted annually in the digital health sector since 2010 [13].

The survey uses standardized questionnaires to provide information about the prevalence, impact, and development of digital health apps. These questionnaires are distributed to patients across Germany through health-related websites, newsletters, and online communities. The participation is anonymous and voluntary. There are no defined exclusion or inclusion criteria other than participation in the online survey and completion of the entire questionnaire. The ePatient Survey 2018 was conducted between March 1 and May 1, 2018. A total of 37,589 participants were included, of which 9664 datasets were complete and a final 9621 were evaluated. The LimeSurvey software (Hamburg, Germany) was employed to conduct the survey. The evaluation of this survey assessed the responses to the following eight questionnaire items, with multiple answers allowed, where applicable:

These questions were categorized according to TAM into questions assessing the “perceived use” and the “perceived ease of use.”

The average age of the respondents in the study was 59.7 years (SD 16 years). The majority of the respondents aged <40 years were female (n=6735, 70%). In contrast, 60% (n=5773) of the respondents aged >70 years were male [13]. In terms of the educational level, 41% (n=3945) of the respondents had a university or technical college degree, 40% (n=3848) had a high-school diploma (“Realschulabschluss”) or a university-entrance diploma (“Abitur”) without higher studies, and 18% (n=1732) had a certificate of secondary education (“Hauptschulabschluss”). In an all-German comparison, the academic rate in the survey was well above average, which did not significantly affect the study’s validity [13]. In addition, 72% (n=6927) of the respondents had government insurance, while 11% (n=1058) had a private insurance and 17% (n=1636) had both.

The most common type of health care app was an online medical appointment scheduling app (n=2309, 24%), followed by tracking apps (n=1827, 19%) that record all types of data collections. Coaching apps (n=1347, 14%) and an online medical second opinion app (n=770, 8%) were also in relatively widespread use. Apps for diagnosis (n=577, 6%), check-ups (n=385, 4%), online health records (n=241, 2.5%), and online medical consultations (n=96, 1%) were less widely used [13].

Long-term patients with chronic diseases accounted for the greatest proportion of users (n=4041, 42%); this group consisted of predominantly male patients with an average age of 63.3 years and no academic background. The majority of those with chronic diseases (n=2966, 73.4%) were receiving treatment at the time of the survey, with 51% (n=1513) of these patients taking medication, 19% (n=564) taking part in physical therapy, and 17% (n=504) receiving regular outpatient and inpatient treatment in a clinic.

Diseases for which digital apps were employed included primarily diseases of the locomotor system (n=1948, 27%), cardiovascular diseases (n=1876, 26%), and metabolic diseases (n=1448, 20%), followed by pain syndromes (n=938, 13%), psychiatric disorders (n=866, 12%), and ophtalmological diseases (n=721, 10%). The second largest group comprised patients with acute conditions (n=3175, 33%), with an average age of 56.6 years, and this group had a higher proportion of women (n=2000, 63%). Users in this category tended to be college graduates. Healthy users made up the smallest group (n=2405, 25%), with an average age of 58.6 years and no sex-relevant tendencies; this group had a significantly higher proportion of university/college graduates [13]. Most patients were receiving ongoing treatment during the survey and thus used the internet more frequently. The second most common phase was change of treatment or desire for a change; this phase was associated with slightly increased internet usage [13].

The intensity of digital medical app use was classified into nonusers, users, and intensive users. Nonusers were defined as never having used any digital medical app due to the lack of need for or interest in such apps. People in this category showed a limited willingness to share their data and a certain mistrust toward anybody but their physician. The average age in this group was 63 years, 4 years above the overall age average of 59 years. The level of education of people in this group was slightly lower than that in the user group [13]. The user group comprised people who regularly used digital apps for medical devices, medication, coaching, and obtaining a second opinion online. People in this group had a higher level of knowledge, a higher need for an online health record, and were generally more willing to share their personal data.

Of the respondents aged ≤40 years, the majority were women, while a higher proportion of men were observed in the age group of those aged >60 years. The average age in this group of 52 years was 7 years below the average age of 59 years. This user type had a slightly higher level of education than nonusers. Intensive users exhibited the greatest need for online medical records and consequently had the highest knowledge. The most frequently used apps in this group were, similar to the user group, those for medical devices, medications, coaching, and obtaining an online second opinion. Every second person in this group had completed an academic degree [13]. The average age was the same as that in the user group (52 years)—7 years below the overall age average. A higher age correlated with a higher proportion of men.

The evaluation results of the responses to the questionnaire items are summarized in Table 2.

The decision to integrate new technologies in the health care industry depends on different factors common to patients, medical professionals, and health care providers. Knowledge on the attitude of potential users toward such technologies eventually determines their success on the market. In this study, we therefore assessed the frequency of use of different digital medical apps in Germany to characterize the current user population and identify the perceived usefulness and ease of use of such apps.

Our most important findings and a brief discussion of each finding are presented below.

The perceived usefulness of the apps was positively supported by the statement from most patients that such an app helped them regularly take their medication. Nonetheless, most users did not use the app for an extended period of time, with less than a quarter of the respondents continuing its use for a year or more. The acceptance is therefore apparently very short-lived and may limit the potential benefits (eg, long-term apps such as storage of the medical history). The most prominent perceived usefulness is the sharing of data stored in an app with their attending physician. In contrast, online coaching programs were not perceived as a helpful tool by most participants, with only one-third noting an improvement in their daily life after participating in such a program. If the users fail to see any long-term value in online coaching programs, the probability of acceptance likely decreases. Of note, the use of such programs has increased from 5% (n=200) in 2016 to 14% (n=1485) in 2018, likely due to increasing advertisement and a broader availability of such different programs.

In terms of the perceived ease of use, we discovered that users of medical digital apps are still facing minor or major difficulties in operating them. Furthermore, there appears to be a discordance between the preferred access to such apps (ie, the attending physician) and the actual way such apps are accessed (ie, the internet). At the same time, nonusers frequently showed a certain distrust toward people administering such apps other than their physicians. In addition, 72% (n=6927) would prefer to receive this app from the attending physician. This shows a clear divergence between the distribution channels actually used and the distribution channels desired.

Thus, the physician is clearly preferred to other parties (such as a hospital, health insurance fund, and medication manufacturer). User confidence is a crucial factor in the long-term acceptance of new technologies. There is generally a relationship of trust between the patient and the (family) physician that is sometimes built up over several years. To make the introduction of innovative technologies sustainable and promising for the user, it is advisable, based on current data, to have the attending physician function as the direct distribution channel.

An online health record system could facilitate the documentation of a patient’s case history and prove to be cost-effective. Such a record system, the Siemens patient records system, was used in Austria as part of the digiLog project [16]. In this system, patient data were stored as a mobile electronic file and could be shared between the attending physicians and the patient [16]. However, the online health record has been receiving a low participation to date (n=241, 2.5%), possibly due to its pilot project status due to limited health insurance funds, making it accessible only to privately insured patients [13]. Its nationwide use requires the right framework, such as a basic social understanding of the benefits of such a record system and strategies for building and disseminating it [12].

In our study population, there was a low level of awareness of online patient record systems among female respondents and an apparent lack of interest in younger male respondents with a higher level of education. We speculate that a low level of awareness might prevent patients from using the available apps. An app’s acceptance is generally linked to awareness of its capabilities. Hence, an increased promotion of digital medical apps, ideally by the person of trust, namely, the physician, could potentially increase their acceptance among patients.

Acceptance must be further differentiated according to sociodemographic factors and the types of the respective apps [17,18]. A recent study has shown relatively lower acceptance rates in older individuals [19]. Respondents in this study were 59 years old on average, with most of the respondents aged between 44 and 76 years. An extrapolation of our results to a younger population is therefore not possible, and we cannot judge the acceptance in younger adults in our cohort.

Several recent reports have addressed the acceptance of digital health technologies in specific cultural and socioeconomic settings. A pilot study in female respondents in rural Uganda has shown overall openness among the respondents to accept computer-assisted personal interviewing. The implementation of such a technology can, in the long run, be very beneficial for the community because it would provide a cost-effective and more easily accessible health care alternative [20]. It appears crucial that the anxieties and insecurities of both patients and medical professionals are considered to increase the chances for their acceptance [21].

Digital medicine has great potential to bring individualized health care solutions, but challenges for their successful implementation still exist. Many apps still need to be validated in clinical settings and, often, initial pilot studies may be underpowered [22]. Ethical challenges also need to be addressed, such as concerns about the confidentiality of personal data [23,24].

The survey revealed significant differences in the current spread, use, and perception of digital health technologies among users in Germany. Suitable framework conditions must be generated, particularly in the case of groups that currently still show a low level of acceptance of specific apps (including online patient records and online second opinions). Such conditions must take into account socioeconomic aspects and the use of apps by the younger generation as well as sex differences. Patients must also be informed about the capabilities of the app and a suitable offer must be made available.

The obvious limitation of our study is the average age of the respondents—59 years. This can most likely not be considered representative of the German population as a whole, which had a median age of 47.1 years in 2018 [25]. The reason for this high average age can be attributed to the type of channels through which the ePatient Survey was distributed, namely, health-relevant websites and newsletters, whose readership is typically older.

Our evaluation demonstrates the acceptance of medical digital technologies among a selected population group in Germany, primarily as tools to communicate with the attending physician. Our findings highlight the need to generate a framework for such technologies by increasing the knowledge on their existence and benefits and supporting them with respective funds from the health care providers.