From privacy to usability: What shapes public trust in Germany’s new EHR system

Germany's Electronic Health Records (EHRs) are set to revolutionize digital healthcare, but trust remains a key challenge. This study explores privacy, security, usability, and public perception, highlighting what it takes to build confidence in the nationwide EHR rollout.

Governments and healthcare systems worldwide are rapidly transitioning to Electronic Health Records (EHRs) to enhance healthcare accessibility, efficiency, and patient outcomes. While many countries implement these systems with varying levels of user participation, Germany has taken a unique approach by automatically enrolling all citizens unless they opt out. This shift presents significant benefits, including streamlined communication between healthcare providers, improved patient care, and cost reductions. However, a recent study highlights a crucial factor determining its success - public trust.

A research paper titled "Trustworthiness of the Electronic Health Record in Germany: An Exploratory, User-Centered Analysis", published in Frontiers in Digital Health (2025) by Niklas von Kalckreuth and colleagues, examines the factors that shape trust in Germany’s EHR system. The study involved semi-structured interviews with 30 participants, who interacted with an EHR prototype and provided feedback on their experiences. Their findings reveal five primary factors influencing trust: provider reputation, user feedback, content experience, functional experience, and user data control.

Reputation and user feedback: The foundation of trust in Germany’s EHR system

A major determinant of trust in digital health services is the reputation of the EHR provider. The study found that patients were more likely to trust EHR systems associated with well-established healthcare organizations and technology firms. Participants viewed platforms developed in collaboration with reputable health insurers and medical institutions as more credible, while lesser-known digital platforms faced skepticism.

One key insight from the study is the role of strategic partnerships. Users expressed higher confidence in EHRs backed by recognized technology firms specializing in data security and privacy. An EHR system endorsed by a renowned IT company signals strong encryption standards, compliance with GDPR regulations, and robust security protocols, all of which contribute to public trust.

User feedback also emerged as a critical trust factor. Participants placed significant emphasis on app store ratings, online reviews, and social proof. High download numbers and positive ratings were perceived as indicators of security and efficiency, whereas news of data breaches or privacy violations severely damaged trust.

Beyond institutional credibility, word-of-mouth recommendations from friends, family, and healthcare providers played a major role in shaping attitudes toward EHR adoption. Many participants stated they would be more inclined to use an EHR system if someone in their personal network recommended it. This finding highlights the importance of public awareness campaigns and transparent communication strategies to foster widespread trust in the system.

How design, usability, and transparency influence EHR adoption

The study also found a strong connection between user interface design and trust. Participants responded more positively to modern, intuitive designs, associating them with professionalism, security, and reliability. Conversely, outdated designs, complex navigation, and inconsistent formatting raised doubts about the system’s dependability.

Readability and clarity were equally important. Users preferred well-structured, jargon-free explanations of system functions, privacy policies, and data handling practices. If the language was too complex or ambiguous, participants suspected that important details were being hidden, leading to lower trust levels.

EHR usability was another key trust factor. Participants expected the system to be fast, error-free, and consistent across different platforms (desktop, tablet, and mobile apps). Technical glitches, slow load times, broken links, or system errors negatively impacted perceptions of reliability.

Customer support availability further influenced user confidence. Participants preferred human support channels, such as phone and email assistance, over automated chatbots and FAQ sections. A lack of accessible customer support was perceived as a red flag, particularly regarding security or data privacy concerns.

Privacy, security, and user control: Germany’s key EHR concerns

Data security remains the biggest challenge to widespread EHR adoption in Germany. The study confirms that users are deeply concerned about who can access their health records and how their data is protected. Participants only trusted EHR systems that clearly communicated encryption protocols, GDPR compliance, and secure data storage practices.

A defining feature of Germany’s EHR system is data sovereignty, which grants patients full control over their health records. Unlike in many other countries, German EHR users can upload, delete, and manage access permissions for their medical data. This level of autonomy was widely appreciated, as it reassured participants that they retained ultimate control over their sensitive information.

However, the study also revealed usability challenges linked to privacy settings. Many participants struggled to navigate complex data-sharing controls and worried that choosing the wrong settings could accidentally expose their medical information. Researchers suggest implementing predefined privacy options (e.g., “high privacy,” “standard,” “public”) to simplify data management and reduce user anxiety.

Another major concern was data storage location. Participants strongly preferred EHRs that stored data on German or European servers, citing GDPR protections as a key factor. Trust levels dropped significantly if data was stored in countries with weaker data protection laws.

Finally, authentication and security measures played a crucial role in shaping trust. Participants favored multi-factor authentication (MFA), biometric logins, and one-time passwords as essential security measures. Lack of strong authentication protocols was viewed as a serious vulnerability, regardless of how well-designed the EHR system appeared.

Future of EHRs in Germany: Building a trustworthy system

The study stresses that trust is the cornerstone of successful EHR adoption. Germany’s opt-out model makes it essential for policymakers and healthcare providers to prioritize transparency, security, and user control. Ensuring that data protection laws are strictly enforced, privacy settings are user-friendly, and customer support is readily available will be key to gaining public confidence.

For healthcare organizations and technology developers, these findings provide a clear roadmap for building more user-centric EHR systems. By addressing reputation concerns, improving user experience, and reinforcing security measures, Germany’s healthcare system can successfully transition to a digital-first approach while maintaining strong public trust.