The Hospital Future Act (Krankenhauszukunftsgesetz, KHZG) was passed by the German Bundestag in September 2020 to enhance digital infrastructure in German hospitals. The evaluation process involved the conduction of the so-called DigitalRadar survey to evaluate the digitalization status of German hospitals [2]. In 2022, a preliminary report was released, indicating that 1624 hospitals had an average advancement level of 33.3 out of 100 points. However, it should be noted that the majority of the questions in our survey were specific to radiation oncology departments. As a result, our findings cannot be directly compared to those of the broader DigitalRadar survey, which encompassed a wider range of healthcare departments such as surgical departments and emergency wards. To the best of our knowledge, this is the first survey to evaluate the digitalization status of a specific healthcare specialty.

Electronic health records can improve quality of healthcare [3]. In 2021 Ribelles et al. found electronic health records to be almost universally implemented in medical oncology departments in Spain [4]. In our survey of radiation oncology departments, we found about half of all departments to be fully paperless and another 20% to be partially paperless. Additionally, in 13.3%, this was planned in the near future.

In the context of radiotherapy planning, both in-house scripting solutions and automated contouring and planning tools play pivotal roles in shaping the digitalization of the field. In-house scripting solutions, used by 21.7% of surveyed institutions, offer customization and adaptability, catering to the unique workflows of each department. They provide seamless integration with various software systems and interfaces, adapting as these systems evolve [5, 6]. However, these scripts pose challenges due to their bespoke nature, including the potential for failure and the lack of standardized implementation processes. These factors could hinder their widespread adoption [7, 8]. Furthermore, the relatively low percentage of institutions using in-house scripting might be attributable to a lack of coding skills in radiotherapy departments. Furthermore, 9.1% of the participants expressed concern about the scarcity of specialists, even if coding abilities were present. Additionally, the limited coding access to software products necessitates extensive collaboration with the industry.

Simultaneously, the survey highlights the increasing adoption of automated contouring and planning tools. These tools enhance efficiency, allowing healthcare professionals to focus on patient care. They also improve accuracy and consistency in tasks requiring high precision, leading to more effective treatment plans [9]. AI-based tools add the advantage of adaptability, improving performance with increasing data inputs, and can manage extensive data volumes and complex computations [10, 11]. Despite challenges such as ensuring reliability, data privacy, and seamless workflow integration, these tools represent a significant advancement in radiotherapy.

The use of smartphone applications in the healthcare system has become increasingly common among patients with various diseases. In Germany, the Digitale-Versorgungs-Gesetz (DVG) law, which came into effect in 2019, aimed to accelerate the digitalization progress in healthcare [12]. One aspect of this law was the introduction of the possibility to prescribe smartphone apps, known as DIGA. Since then, there has been a steady increase in the prescription of these apps, as reported in the tk-diga report of 2022 [13]. However, in our survey specifically focused on radiation oncology, we found that only 4.8% of institutions were utilizing this option. This low usage could be attributed to the limited number of DIGA applications available in the field of oncology. While the majority of the approximately 50 approved DIGA applications served psychological purposes, only two applications focused on oncology [14]. Furthermore, these two applications were designed for breast cancer patients and not specifically for radiotherapy patients. This fits well with a previous report of the DEGRO working group reviewing apps in the field of radiation oncology [15]. In line with low rates of DIGA application, the utilization of smartphone apps for collecting ePROMs (electronic patient-reported outcomes) was not widespread, possibly due to hesitation in the radiation oncology field where older patients may have limited familiarity with digital technologies. This poses a challenge for app designers to prioritize easy access and user-friendliness, especially for older individuals. However, with the significant increase in smartphone usage in recent years and the projected continuation of this trend, there is an expected future demand for improved accessibility. It is noteworthy that a majority of participants would endorse the provision of medical society-proven smartphone apps (e.g., for collecting ePROMS).

In a survey conducted by the German digital organization Bitkom in 2023, a total of 505 businesses were asked about their internal and external communication methods. The results showed that 82% of the companies still used fax as a means of communication and approximately one third of the companies reported using fax often or very often. However, the frequency of intensive fax usage (40%) had decreased compared to 2018 (62%; [16]). These findings are consistent with our radiation oncology-based research with a general fax usage by 71.7% of all departments, and even 80% of all German departments. It is noteworthy that communication experts have raised concerns about the compliance of fax technology with modern-day European Union data protection laws (Datenschutz-Grundverordnung, DSGVO). Furthermore, Austria has implemented national legislation that restricts the use of fax machines to exceptional cases with strict limitations [17]. The prevalence of fax usage may be attributed to the absence of highly secure email accounts among partners. Additionally, radiotherapy facilities in major hospitals frequently rely on their own internal networks, as mandated by linear accelerator manufacturers, resulting in limited connectivity to hospital databases.

Modern image-guided radiotherapy is dependent on IT and data storage applications that are at risk from cyberattacks [18]. In the past 10 years, numerous attacks have led to an interruption of radiation therapy for thousands of patients worldwide [18]. Based on these cases, several recommendations have been published [18,19,20]. These recommendation range from staff education programs, multifactor authentications, software updates, e‑mail protection filters, and antivirus programs. In line with those recommendations, our survey also revealed a high percentage of daily backups (69.2%), regular staff education (53.3%), virus scanners (70%), spam filters (65.8%), and firewalls (72.5%). Moreover, one key point is having an in-house team with knowledge and understanding of IT related to radiation oncology [19]. In our survey this applied for half of the radiation oncology departments. Still, rating the future challenges in digitalization, data safety and cyberattacks were the most common concerns in our survey.

In recent years, the number of educational resources has increased. A review by Culbert et al. showed e‑learning to be actively integrated into radiation oncology training programs [21]. Even though this study was specifically focused on resident physicians, it aligns with our findings of a significant proportion of continuing education programs being offered in digital format, with rates of 75.8% for physicians and 72.5% for medical physicists.

The results of our survey showed that university hospitals have a higher percentage of paperless patient records and in-house scripting solutions compared to non-university hospitals. Additionally, digital interfaces for data transfer were found to be more common in university hospitals and private practices than in non-university hospitals. These findings suggested that university hospitals may have a more innovative approach than non-university hospitals, which was consistent with a previous analysis of radiotherapy institutions in 2010 [22]. By contrast, however, universities had shortcomings in providing digital alternatives for teaching.

Based on our survey findings, we observed certain discrepancies depending on the national association of the participants. Switzerland, in particular, demonstrated a higher level of innovation, with greater adoption rates of fully paperless patient records, AI-adapted auto-contouring, and automatic planning tools. German radiation oncology departments relied heavily on fax for communication with external colleagues whereas Switzerland radiation oncology departments preferred e‑mails. This fits well with the IMD (International Institute for Management Development) World Digital Competitiveness Ranking, which is published every year. This measures the capacity and readiness of 63 economies to adopt and explore digital technologies as a key driver for economic transformation in business, government, and wider society. Switzerland climbed to the fifth position in the 2022 report, while Germany and Austria remained stagnant at 19th and 18th place, respectively [23]. Although this ranking does not directly reflect the level of digitalization in healthcare, it aligned with our results.

These findings were also in line with a more recent report on healthcare systems by the German Bertelsmann Stiftung, which focused on smart health systems in various European countries, as well as Australia and Canada. The report used 34 indicators to create a digital health index, which encompassed three categories: policy activity, digital health readiness, and actual data utilization. Germany received a digital health score of 30 out of 100, placing it 16th out of 17 countries. Austria and Switzerland achieved scores of 60 and 41, respectively, placing them 10th and 14th [24].

Overall, satisfaction with workflow and automatization was rated positively with only 15% and 12.5% of participants being (very) unsatisfied with those issues.

However, when it came to data transfer, satisfaction levels were lower, with 25% of participants expressing dissatisfaction. This sentiment was echoed in the open-ended responses, where nearly half of the participants identified data transfer/interfaces and data safety as the primary challenges for future digitalization. Furthermore, when it comes to digital data transfer between different institutions, a wide range of diverse solutions were observed. This indicates that there is currently no established standard in place.

In total, approximately 50% of the participating institutions had a specific digitalization strategy planned for the upcoming years. Conversely, a significant majority (73.3%) expressed a strong inclination to further digitalization.

Over the past few years, various surveys on different healthcare topics have been published in the German-speaking radiotherapy community [25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40]. One of the main limitations of these surveys was the low return rate of completed data, which was often correlated with the size of the collective being surveyed. Our survey achieved a higher rollback rate (33.4%) compared to other surveys of similar scale. This is noteworthy considering the larger number of individual questions (n = 53) in our survey, compared to a range of 14–42 (median: 26) in the aforementioned surveys.

Nevertheless, the findings of this predominantly descriptive study should be interpreted with caution as the ability to draw correlations was limited due to the relatively small subgroups comprising approximately 30% of all institutes.

Furthermore, it is important to consider that a potential constraint of our research was that over 90% of the participants expressed a significant level of technical interest. This could have introduced a potential bias toward subjective inquiries, such as those pertaining to satisfaction.