Accessing Germany's Electronic Patient Record Through Health Insurer-Provided Apps: Qualitative Interview Study.

BACKGROUND: Nationwide electronic health records (EHRs) are intended to strengthen patient empowerment and improve information continuity across health care settings. In Germany, the electronic patient record (elektronische Patientenakte [ePA]) transitioned from an opt-in to an opt-out model in 2025. Initial survey data suggest that technical complexity and access requirements may hinder engagement; yet, little is known about how users experience this access process. OBJECTIVE: This study explored users' experiences of setting up and authenticating access to insurer-provided ePA apps and examined the barriers affecting successful access. METHODS: We conducted a qualitative interview study with individuals covered by statutory health insurance. From 61 interviews conducted within the broader ePA4all project, 23 were selected because participants had attempted to access the ePA through an insurer-provided application and described at least 1 concrete action or event during setup or authentication. Semistructured telephone interviews were conducted between August and December 2025. Data were analyzed using Kuckartz's structured qualitative content analysis. The process phases were developed inductively from the material. All 23 interviews were independently coded by 2 researchers, with differences resolved through consensus. A second analytic step examined how barriers interacted and accumulated across the access pathway. RESULTS: The sample included 21 participants who had successfully accessed the ePA and 2 who had initiated but abandoned setup or authentication. Setup and authentication were experienced not as a single technical step but as an interdependent process comprising 5 phases: orientation, technical entry, verification, interruption, and transition to initial use. During orientation, incomplete or outdated information left requirements and procedural steps unclear. Technical entry required users to coordinate different apps, interfaces, and device requirements. Verification involved multiple credentials, identification services, and partly repeated security steps. Technical failures, administrative inconsistencies, postal procedures, and waiting periods interrupted progression and sometimes required users to repeat previously completed steps. After successful access, an unclear immediate benefit could limit the transition to initial use. Across phases, participants relied on digital competence, prior experience, persistence, and self-efficacy to navigate the process. Difficulties were also reported by participants with high affinity for technology. Barriers could accumulate across phases: insufficient orientation increased subsequent coordination work, failures produced interruptions and repeated attempts, and prolonged effort contributed to frustration or disengagement. CONCLUSIONS: Access to the opt-out ePA through insurer-provided apps is shaped by cumulative demands rather than by isolated technical problems. Formal provision of an EHR does not ensure that users can successfully complete the access process. Implementation should prioritize clear preregistration guidance, continuity across applications and identification services, resumable procedures, actionable error messages, and accessible support. More broadly, onboarding and authentication should be treated as integral stages in the implementation of patient-facing digital health infrastructures rather than as neutral technical prerequisites. TRIAL REGISTRATION: German Clinical Trials Register DRKS00037053; https://www.drks.de/search/de/trial/DRKS00037053. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1177/20552076251407130.