The 116117 Help Line in Germany

The digitalization of the German healthcare system offers considerable potential to improve the delivery of care. Digital access pathways to the care system could, among other things, make it easier to reach hard-to-access target groups and mitigate the effects of workforce shortages. Since 2020, the 116117 patient assistance helpline provided by the German Associations of Statutory Health Insurance Physicians (ASHIPs, Kassenärztliche Vereinigungen) has been available by telephone nationwide 24 hours a day, 7 days a week, for people with health-related complaints. For the initial medical assessment, the specially trained healthcare professionals use the software SmED (Structured Initial Medical Assessment in Germany, Strukturierte medizinische Ersteinschätzung in Deutschland) (1, 2). This software is certified as a Class IIb (medium- to high-risk) medical device in line with the EU Medical Device Regulation. Since December 2021, the telephone service has been supplemented by a digital option for self-assessment. The feature referred to as the “online patient navigator” is available via the 116117 patient services website (www.116117.de/de/patienten-navi.php). Here, individuals seeking help can carry out an SmED self-assessment using a chatbot. Based on age, sex, signs of an emergency, acute and chronic medical problems, as well as risk factors, SmED provides recommendations, both by telephone and online, regarding how rapidly individuals seeking help should obtain further medical evaluation and which service to contact (112, an emergency department, or a medical practice). No diagnoses are made. Depending on the SmED result as well as the region, day, and time, patients have the option to immediately book a physician appointment via an appointment portal (by telephone in all cases; online in currently 14 ASHIPs). The aim of the study was to analyze the use of online self-assessment compared with telephone-based initial assessment. The user-friendliness of the online self-assessment was also examined.

Methods

We conducted a quantitative, retrospective study using anonymized nationwide SmED data from the period 2022–2024 (online and telephone assessments) in which at least one complaint was recorded (assessments in which “fear of permanent health damage” was given as the reason were excluded, since this complaint category was only introduced in SmED in November 2024). Usage times and user characteristics in the two groups were analyzed descriptively. To assess userfriendliness, we used data from an anonymous online survey that was accessible to all users following completion of their self-assessment (between 02/2023 and 12/2024). Statistical analyses were performed using R version 4.2.2.

Results

A total of 897 232 online self-assessments and 6 067 734 telephone assessments were included in the analysis. In both groups, slightly more than half of those seeking help were female (online: 57.0%, telephone: 58.2%), and the largest proportion was in the 14- to 49-year age group (online: 69.1%, telephone: 32.2%). Individuals in the 50-year and older age groups (50–65, 66–80, > 80 years) were more likely to use the telephone service (online: 15.8%, telephone: 54.1%). Individuals with complaints relating to their mental health and reproductive organs were markedly more likely to undergo an online self-assessment than use the telephone service (by factors of 4.6 and 1.9, respectively); the converse pattern was seen for individuals with musculoskeletal/joint and general complaints (by factors of 1.5 and 1.4, respectively). The self-assessment group showed a higher proportion of emergencies and cases with a recommendation for emergency services or an emergency department compared with the telephone consultation group (Table).

Table. Characteristics of individuals seeking help by access pathway.

	Telephone consultation	Online self-assessment
n	6 067 734	897 232
Sex
Male	41.7	38.8
Female	58.2	57.0
n.s.	< 0.1	4.2
Age group
< 14 Years	13.8	11.0
14–49 Years	32.2	69.1
50–65 Years	15.6	10.0
66–80 Years	17.6	3.6
> 80 Years	20.9	2.1
n.s.	< 0.1	4.2
Time of day
Daytime (08:00–19:59) vs. nighttime	69.6	67.8
Day of the week
Mon-Fri vs. weekends/public holidays	48.6	59.7
Practice opening hours *1
During vs. outside	27.1	38.8
Urgency of care
Emergency	5.1	14.3
Immediate medical care	44.7	42.1
Medical attention within 24 h	33.5	28.9
Medical attention > 24 h	16.2	14.7
n.s./Survey unclear	0.5	< 0.1
Level of care
112/Emergency services	3.4	11.0
Emergency department	24.8	35.6
Contract physician	51.6	41.0
Remote consultation (telephone or video)	19.6	12.3
n.s./Survey unclear	0.6	0.1
Reason category
General symptoms*2	17.4	12.8
Respiratory/cardiovascular symptoms	14.3	13.8
Eye/ENT symptoms	12.6	18.0
Digestive/urinary system symptoms	20.6	15.5
Symptoms of the male/female reproductive organs	1.5	2.8
Skin symptoms	6.1	5.7
Musculoskeletal symptoms	14.9	10.3
Neurological symptoms	3.3	5.0
Mental health symptoms	1.8	8.2
Injury/general pain/bleeding	7.5	7.7

Values are given in percent, except for line “n”

^*1“During practice opening hours,” as specified in the German fee schedule item (Gebührenordnungsposition, GOP) 01210: between 07:00 and 19:00 (excluding Saturdays, Sundays, public holidays, and 24 and 31 December); “outside practice opening hours,” as specified in GOP 01212: between 19:00 and 07:00 on the following day; all day on Saturdays, Sundays, public holidays, and on 24 and 31 December

^*2Allergy symptoms, loss of appetite, blood sugar problems, (suspected) COVID-19, reduced ability to perform everyday activities, cold/flu, fever, frailty, weight changes, immunization reaction, lymph node complaints, fatigue, sunstroke/heat stroke, malaise, poisoning

Source: SmED data for 2022–2024, German Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen)

For the assessment of user-friendliness, responses from 2540 users were available (response rate, 0.3%). Nine out of 10 users reported that they were immediately able to navigate the system (91.5% yes/rather yes) and that the questions were easy to answer (91.6% yes/rather yes). A total of 72.4% would recommend the online selfassessment to a friend or acquaintance with acute health problems.

Discussion

The two access pathways to initial assessment (online and via telephone) were used by different groups of individuals. Satisfaction with the online tool was high. While the telephone service was used more frequently by individuals aged 50 years and older, the online service could contribute to improved entry into care for younger people and individuals with mental health-related complaints. However, users’ subsequent uptake of the service cannot currently be tracked. Thus, it remains unclear whether and, if so, which healthcare services were used following the online self-assessment.

Comparable online services in England (National Health Service [NHS] 111 Online [3, 4]) and the Netherlands (the moet ik naar de dokter app [5]) showed a similar age-related pattern, with higher utilization among younger age groups (England, 16- to 35-year age group: telephone 31.2%, online 61.1%; the Netherlands, 19- to 45-year age group: online 56.4%). The proportion of cases for which the online self-assessment resulted in an “emergency services” recommendation appears high at 11.1%, but is slightly lower than that reported in England (14.8%). However, these cases, as well as those with an “emergency department” recommendation, require further investigation. Individuals with an emergency department recommendation are currently advised online to call the 116117 helpline for further evaluation. Possible reasons for the increased proportion of emergencies may include trial uses of the service that do not constitute serious requests for help, as well as misinterpretation of the questions and response options during the initial screening for obvious emergency indicators; 61.8% of emergency cases resulted from this step (not shown). Initial pilot projects offer one approach to analyzing potential causes, whereby self-assessments conducted by individuals seeking care in out-of-hours practices and emergency departments are compared with subsequent assessments by healthcare professionals.