This study was approved by the ethics committee of Witten/Herdecke University, Faculty of Medicine (application No. 169/2016), and conducted using an instrument development model which was divided into Part A and Part B, as described by Schifferdecker [18]. Part A was a qualitative study consisting of the conceptual approach of the Grounded Theory developed by Glaser and Strauss [19-21]. Interviews were done via telephone or face-to-face using an open interview guide (see Multimedia Appendix 1). The recorded responses were anonymous and were qualitatively evaluated using MAXQDA 13 (VERBI Software GmbH, Berlin, Germany) until saturation of hypotheses was reached. Part B represents a quantitative study using an online survey, based on the Delphi method, to test the generated hypotheses on the general public [22]. The results were then analyzed using MiniTab, version 17.1.0 (Minitab GmbH, Munich, Germany).

For Part A, expert participants were chosen using the criteria of their job position in the German health care system. According to Glaser and Strauss, a heterogenic sample of participants is recommended to maximize the variations of experience within the group [19]. Therefore, we approached as many different healthcare experts that were concerned with innovation as possible to be participants in our study, to ensure a wide variety of insights for defining hypotheses. We also included senior executives and other senior stakeholders who were focused or had knowledge of the German health care system.

For Part B, surveyed participants from academia (eg, university medical centers) and private hospitals were asked to fill out four questions regarding their demographic background (age group, role in the health care system, job position, and country). We further reached out to patients and service providers (eg, employees of insurance companies). A six-point Likert scale ranging from one to six was used to assess each hypothesis.

Part A data was collected from February 2017 to May 2017 via telephone or face-to-face interviews. Each interview was audio recorded with the permission of the participants. For Part B, the survey was published on SoGoSurvey and data was collected from November 2017 to February 2018.

The participants of this mixed methods study were informed upfront about data storage, the scope of the study, and the interviewer.

To assess the impact and influence of digitization on the German health care system and to obtain a general perception about it, an open interview guide was developed based on literature research and an expert panel consisting of members with multi-professional backgrounds in medicine, pharmaceuticals, and economics. Before using the interview guide for the study, it was tested in five pilot interviews, reviewed, and revised by the expert panel. The coding was performed based on the conceptual approach of the Grounded Theory [19] and the process was supported by literature research. The Grounded Theory approach was designed in three stages, starting with open coding, followed by axial coding, and then selective coding. The process was documented in memos to capture the progress and the ideas that emerged while creating the conceptual approach and analyzing the data [19-21]. For the analysis of the interviews, MAXQDA®13 was used to perform comparative data analysis of the quantitative data by two examiners. The interviews were coded without transcription. Further, the derived hypotheses were grouped into categories afterward to further distinguish the impact field of the different hypotheses. Values of the responses from the survey participants higher than 3.5 were considered to be in agreement with the experts, whereas values lower than 3.5 were considered to be in disagreement.

The data from the Delphi study was analyzed using MiniTab, version 17.1.0. For the calculation of the P value, a one-way analysis of variance (ANOVA) was applied under the assumptions of unequal variances and a statistical significance of P<.05.

The results of this study demonstrate an overall limited impact and influence of digitization on the German health care system, based on the perception of the different participating groups. We found great agreement but also areas of incongruity between the various groups.

As Figure 4 shows, the survey participants agreed on the majority of the 17 hypotheses, although to different degrees. There particularly seemed to be a misalignment of opinions between the physicians and the experts. Compared to the service providers with a mean of 4.25, and patients with a mean of 4.15, the physicians had the lowest mean of 3.90 (see Multimedia Appendix 3). Interestingly, in a large study conducted by the US Physician Foundation in 2018, half of the respondents demonstrated a pessimistic attitude about the future [23]. This pessimistic view could be at least one reason the physicians had such a low mean. With respect to the category system, we observed interesting results related to the slow adaption of digitization. Patients agree with the experts from our panel, that main stakeholders are blocking a faster implementation, but physicians and service providers are significantly different and disagree. Nevertheless, if we look at Germany, the reluctance to implement a national electronic health record system due to data privacy issues raised by the German Government postponed this development significantly [24]. Further, the lowest level of agreement within our study was between experts and physicians. This result could indicate that physicians are particularly slowing down digitization, as this group will be among the most impacted in practice. Interestingly, the medical association slowed down the implementation of both telemedicine and the electronic health record in Germany [24,25].

We found great alignment between the survey participants and experts regarding the benefits associated with new technologies. The broad agreement regarding an increase of self-monitoring is one example showing how well digital devices are accepted. As Roess et al stated, more than 1200 mobile Health (mHealth) tools or apps are available that help patients obtain information and monitor their health status [26].

Apart from the technological advantages, the survey participants were not aligned on who would benefit the most from digitization. Although service providers and patients showed agreement with the experts that compulsory insured patients will benefit, physicians significantly disagreed. This could be based on German specifications, since as of 2018 there are 72.8 million people compulsory insured compared to 8.75 million with private health insurance in Germany [27]. Here, physicians have an incentive to treat privately insured patients and especially to provide them with treatments which are not covered by public insurance. Thus, these new forms of treatment often reach only a minority of patients. In comparison to other health care systems, characterized by generally high out-of-the-pocket payments, this might slow down innovation [28].

The relationship between physicians and patients is a very sensitive topic. Experts and survey participants both agreed that technology cannot replace personal contact, however, this data contrasts preexisting research. There are several studies which have demonstrated the benefits of robot applications for nursing and social interaction among older adults, and the high satisfaction of patients who used telemedicine visits or chat-bots [29-31]. In contrast, 78.7% of the physicians who participated in the US Physician Foundation survey pointed out that working with patients is the most satisfying factor in medical practice [23].

In addition to the potential loss of personal interaction, we found misalignment of opinions regarding patient empowerment. According to Topol et al, the introduction of smartphones and applications will empower patients, since they will be able to control all their relevant health care data on one device [32,33]. However, the data showed significant differences between the survey participants, with patients and physicians especially not supporting this hypothesis. This could be explained by a lack of understanding of the opportunities on behalf of the patients and a potential negative attitude among the physicians. There are major initiatives aiming at patient empowerment, eg, Patients Empowerment Campaign from the European Patients Forum and the Patient empowerment and health care guidelines from the World Health Organization. Both define processes and activities to enable patients to have greater control over decision making and consequential actions related to their health [34,35].

We also found disagreement among the survey participants regarding the depreciation of expert knowledge. Physicians seemed especially concerned, since they disagreed with the hypotheses about the replacements of jobs using AI applications. On the one hand, the physicians agreed with the results of recent studies which have already demonstrated technological potential for improved diagnostics and surgical decision making [36,37]. However, the responses indicate an underlying negative attitude among physicians regarding digitization when technology is no longer supporting but instead limiting or replacing their activities. This is problematic in two ways: (1) they could be detached from technological progress, with the threat being replaced in some areas; and (2) they are missing the opportunity to actively participate and enhance these new technologies with their experiences to achieve higher quality standards for their patients.

This study was performed within the German health care system with experts in Germany. While patient needs are comparable to other western societies, specific aspects in Germany (eg, a diverse payer and provider landscape compared to the United Kingdom) might limit its applicability to other systems. Therefore, the implications derived from this study concerning the common understanding of the impacts and influences of digitization might not be applicable to other health care systems in the world.

The digitization of the health care sector in Germany could cause significant changes, and only the future will tell how different stakeholders will be able to adapt. According to our research, the current adaptation level varies strongly among different participants in the market. For some of them we found significant alignment of opinions between experts and survey participants (eg, referring improved medical treatment, standardized communication structures, increased self-monitoring of patients and the importance of the personal contact between patient and physician in a digitized relationship). However, substantial agreement gaps exist regarding the empowerment of patients, the application of artificial intelligence and robots and thus the replacement of expert knowledge, particularly between physicians and our expert panel.

Physicians showed a negative attitude towards the empowerment of patients that comes with the process of digitization. They also failed to recognize that, in some areas, they might be replaced by technology. To generate the highest value for patients and to bring the technological advances to patients as fast as possible, it is crucial to involve all stakeholders. This is especially important in cases where job profiles will change. Physicians should acknowledge the change introduced by technological transformation and play a more active and positive role.