The ”Versicherten­stammdaten­management“ (master data management, VSDM) is mandatory and was the first feature of the telematics infrastructure (TI). According to the German law book of Social Code (Sozial­gesetz­buch SGB V § 291), your master data must be stored onto your electronic health card (eGK) and in the telematics infrastructure (TI). It includes your name, date of birth, gender and address, as well as your health insurance company and your (permanent) health insurance number. Since January 2019, every time your eGK is read in a card terminal, the data on your card is compared with that in the TI and corrected if necessary. A correction may be necessary if, for example, you have a new address after moving house. We need the master data for billing with your health insurance company.

The ”elektronische Arbeits­unfähigkeits­bescheinigung“ (”electronic certificate of incapacity for work“, eAU) was introduced on 1^st July 2022. The launch date has been postponed several times due to technical problems. And still, transmission of the certificate to health insurance companys fails from time to time. In case of illness, you therefore receive multiple copies of a paper-based certificate as usual. One of these you still have to send to your health insucance company. One other you have to submit to your employer. This procedure was changed with the ”Terminservice- und Versorgungsgesetz“ (”Appointment Service and Supply Act“ TSVG) of May 2019 and the »Bürokratie­entlastungs­gesetz III« (”Bureaucracy Relief Act III“) of January 2020. In the near future, you will ”only“ have to call your employer to report sick in case of illness. We will issue an eAU digitally and send it (via KIM) to your health insurance company. At the request of your employer, the health insurance company will provide them with information about the beginning and duration of your illness (but nothing more). From our point of view, this new feature can lead to a considerable simplification for you and for us.

The ”elektronische Überweisung“ (electronic referral) is mandatory and will come, but we do not yet know when it will be introduced. Referrals to doctors will no longer be issued in paper form but stored on your electronic health card (eGK). The targeted doctor will then be able to read the electronic referral with the eGK. Because many patients are referred to us as a specialist practice, we welcome this new feature.

The ”elektronisches Rezept“ or ”eRezept“ (electronic prescription) will be mandatory from 2023 and applies to all prescriptions of medicines including narcotics. Using an ”eRezept application“ on your smartphone or tablet computer, you will be able to redeem your prescriptions at a pharmacy. If you do not have a smartphone or do not want to use it, you will receive a paper barcode (”token“) that you present at a pharmacy. This serves as access information for the pharmacy to retrieve the prescription from the telematics infrastructure (TI). With the ”Pflege­modernisierungs­gesetz“ (”Nursing Care Modernisation Act“, DVPMG) of January 2021, an extension to electronic prescriptions was decided. It will include physiotherapy, ergotherapy, speech therapy, nursing care and medical aids. From our point of view, the new electronic prescription still has to prove itself. So far we have not seen such an ”eRezept smartphone application“, although first test runs have been started in July 2021. The advantage of the barcode instead of the ”old prescription“ is not yet clear to us. This alternative is not envisaged, although pharmacies should still be able to process a paper prescription. The failure of a central server of the TI would result in the loss of your electronic prescription. As a patient, you cannot decide against the storage of your personal data (prescriptions) on a central server.

The ”elektronische Patientenakte“ (electronic patient record, ePA) is voluntary and has been in ”test phase“ since January 2021. It is intended as a central storage location for your entire medical record. You have to apply for its use with your health insurance company and will then receive an ”ePA application“ for your smartphone or tablet computer, as well as a six-digit PIN for your electronic health card (eGK). Your health insurance company will suggest some commercial providers who offer ”files“ for your ePA. On the servers of this provider, your health data will be stored in encrypted form. Neither the provider nor your health insurance company must have access to your data. To ensure this, the key for your ePA consists of two parts that are stored on different servers called ”Schlüssel­generierungs­dienste“ (key generating services, SGD) and are only put together on your smartphone or in our practice. Only with the complete key your ePA may be opened. One SGD-server is with your record provider, the other with an operator of the ”Gesellschaft für Telematik“ (German association for telematics "gematik GmbH", link to a German website). You have two options to register in your application. Either your smartphone communicates with the NFC chip of your eGK (most modern smartphones can read it) and you enter your PIN. This is considered the most secure option according to the ”Gesellschaft für Telematik“ and the ”Bundesamt für Sicherheit in der Informations­technik“ (Federal Office for Information Security, BSI). Alternatively, you receive an activation code from your health insurance company, which you enter in your app. You are responsible for maintaining the ePA yourself. You can save or delete documents such as findings, doctor's letters or data you have collected yourself (e. g. blood pressure values) with your application. Additionally, we may transfer documents to your ePA, too. According to the ”Patienten­daten­schutz­gesetz“ (Patient Data Protection Act, PDSG), you have the right to do so. You will have to release your ePA to us using either your eGK and PIN or your ePA application. Only after the end of the ”test phase“, probably from January 2022, will you be able to use your application to specify exactly which document you want to release for how many days and for which practitioner. Until then, you can only release the entire ePA. Without the smartphone application, however, you have no possibility to save, view or delete data, and therefore must give your practitioners the order to do so. From our point of view, there is currently scepticism regarding the usability, privacy and data security of the ePA, which is why we still advise against its use.

The ”Notfall­daten­management“ (emergency data management, NFDM) is voluntary. You may have your family doctor or us store emergency data such as diagnoses, medication, allergies, contact details of your relatives and doctors, as well as the location of documents such as living wills, health care proxy and organ donor card onto your electronic health card (eGK). In case of an emergency, an emergency doctor or paramedic can access this data with your eGK and an electronic health professional card (eHBA). Every access to your emergency data is logged on your eGK. At your request, the emergency data can be deleted again. Additional protection with a six-digit PIN is possible, but we do not recommend it. If you do not remember the PIN, then the data on the card cannot be changed or deleted. However, even without your PIN it would be possible to read your data in an emergency. Unlike in a doctor's practice, you do not have the right to have emergency data transferred to your eGK in a hospital. This was not anchored in the ”Patienten­daten­schutz­gesetz“ (Patient Data Protection Act, PDSG). This is difficult for us to understand, as especially in inpatient care, data is generated that should be documented (e. g. information about implants inserted). Nevertheless, in our view, NFDM is a useful new feature that can save lives.

The ”elektronischer Medikations­plan“ (electronic medication list, eMP) is voluntary. If you take at least three different medications, we will draw up a so-called ”bundeseinheitlicher Medikations­plan“ (uniform medication plan, BMP). From now on, it can be stored additionally and voluntarily as an eMP on your electronic health card (eGK). We, as well as other treating doctors, and now also pharmacists, can make entries. In addition to your eGK, you need a six-digit PIN that you receive from your health insurance company. Because the eMP is secured with your PIN, you have control over who can view, change or delete it. In our view, the eMP could become a useful successor to the BMP. Nevertheless, the BMP will remain mandatory for the time being. Duplicating documentation onto the eGK can be helpful if you do not want to carry your medication list with you in paper form. This would be understandable if you have your eMP on your eGK anyway. Because pharmacists can also make entries, non-prescription medicines are also included in the eMP. In our view, this is a sensible extension.

”Digitale Gesundheits­anwendungen“ (digital health applications, DiGA) are ”smartphone applications“ that patients are supposed to use themselves in order to carry out exercises or self-assessments in the context of their illnesses. If the apps have been tested by the German ”Bundes­amt für Arznei­mittel und Medizin­produkte“ (Federal Office for Drugs and Medical Devices, BfArM), they may be called DiGA and prescribed by doctors. You can find a list of approved DiGAs here (in German language). To obtain a DiGA, you need a prescription from us, which you submit to your health insurance company. From there you will then receive an activation code with which you can download and activate the application. According to the ”Pflege­modernisierungs­gesetz« (Nursing Care Modernisation Act, DVPMG) of January 2021, the data from the DiGA should be transferable to the electronic patient record (ePA).

”Digitale Pflege­anwendungen“ (Digital nursing applications, DiPA) are ”smartphone applications“ that nurses may use in patient care. They were introduced with the Pflege­modernisierungs­gesetz (Nursing Care Modernisation Act, DVPMG) of January 2021. The idea is to have these applications help with documention (e. g. for falls, or for balance exercises). The long-term care insurance funds are to cover the costs. The law is not yet in force. Presumably, you will submit a prescription for a DiPA to your health insurance company, similar to the DiGA.

More features are planned. Vaccination cards, maternity cards, ”U-Heft“ (Documentation booklet of examinations for children) and dental bonus booklets are voluntary and will be stored and maintained in your electronic patient record (ePA). You can grant your doctor access to the documents for processing. These new features can be useful to remind you of appointments such as for vaccinations or screening examinations. As a neurologist's practice, we will probably have little contact with these new features.

The ”elektronische Gesundheits­karte“ (electronic health card, eGK) has been mandatory since 2015 and is issued to you by your health insurance company. Because it contains a chip it is called a ”smart card“. The chip is used for identification and additionally contains a storage capacity of 58 kBytes for your master data, consent to voluntary features of the TI, electronic prescriptions and electronic emergency data. Your name and photo are printed on the front of the card. In addition, according to the ”Patienten­daten­schutz­gesetz“ (Patient Data Protection Act, PDSG), the eGK allows access to the telematics infrastructure (TI) including the ”electronic patient record“ (ePA). To use these features, however, you must first authenticate with a PIN using one of our card terminals. You will receive your PIN from your health insurance company when you apply for the use of an electronic patient record (ePA). The structure and features of the eGK are described in several specifications (links to a German website) by the gematik GmbH (links to a German website).

The ”elektronischer Heilberufs­ausweis“ (electronic health professional card, eHBA) is a doctor's identity card. All our doctors have an eHBA with which they can authenticate themselves to the telematics infrastructure (TI). It is protected by a PIN. A signature with the eHBA is considered legally binding and is called a Qualified Electronic Signature (QES). Structure and functions of the eHBA are described in the specification of the eHBA (link to a German website) by the gematik GmbH (links to a German website).

The ”Kommunikation im Medizinwesen“ (communication in medicine, KIM) is a technical protocol for the encrypted transmission of data via the telematics infrastructure (TI). KIM works similar to an email programme with mandatory encryption. Each message and document is encrypted before being sent, transported via the TI and decrypted again by the recipient (end-to-end encryption). A messenger service is also planned with the possibility of sending multimedia files. Senders have to identify themselves with a ”elektronischer Heilberufs­ausweis“ (electronic health professional card, eHBA) by means of the so-called Qualified Electronic Signature (QES). This way, transmission history remains transparent and manipulation of messages is prevented. Many TI-services are based on KIM, e. g. the electronic doctor's letter or the ”elektronische Arbeits­unfähigkeits­bescheinigung“ (electronic certificate of incapacity for work, eAU). Registration with a KIM service is obligatory for us according to the ”Termin­service- und Versorgungs­gesetz“ (Appointment Service and Care Act, TSVG) of May 2019. The specification is carried out by the gematik GmbH (link to a German website).

The ”Qualified Electronic Signature“ (QES) was introduced to provide a signature for digital documents. This assures recipients of medical data about the identity of the sender. An electronic health professional card (eHBA) is required for a QES. It is considered a legally binding signature.

The ”eHealth connector“ is a sealed VPN router that connects our practice network with the central servers of the telematics infrastructure (TI). All communication with the TI, signatures and encryption/decryption are provided by the connector. A device card (”gSMC-K“) is installed in each connector, which uniquely identifies the connector to the TI. The specification (link to a German pdf) is carried out by the gematik GmbH (link to a German website).

The ”eHealth card terminals“ are the devices in our practice into which you insert your electronic health card (eGK). The card terminal is equipped with numeric keys to enter your PIN (similar to an ATM) in order to identify yourself to the telematics infrastructure (TI). Each card terminal contains a PIN-protected SMC-B card as an ”institution ID“, which authenticates our practice to the TI. The card terminals are directly connected to the ”eHealth connector“. The specification (link to a German pdf) is carried out by the gematik GmbH (link to a German website).

A ”digital identity“ is a set of electronically available information sufficient to authenticate a person or institution to a computer. This is done at a low security level by entering a username-password combination. But passwords can be stolen. Therefore, if higher security is required, further procedures are necessary. A typical example is ”two-factor authentication“ in online banking, where different devices are used. In the telematics infrastructure (TI), certificates on ”smart cards“ are used to digitally represent connectors, medical practices, insured persons (you) or doctors (us). Your smart card is your electronic health card (eGK), while ours is the electronic health professional card (eHBA). The ”Pflege­modernisierungs­gesetz“ (Nursing Care Modernisation Act, DVPMG) of January 2021 introduced digital identities to ensure, for example, that the person you are talking to during video consultations is who they say they are. You will probably identify yourself from home with a certificate on your smartphone and by entering a PIN.

Telemedicine, a made-up word from ”tele“ (Greek τῆλε = far away) and ”medicine“ stands for medical treatment at a distance. During the coronavirus pandemic, the need for telephone or video consultations became apparent. However, basic principles were already laid down in the »E-Health-Gesetz« (E-Health Act) of May 2015. In the »Pflege­modernisierungs­gesetz“ (Nursing Care Modernisation Act, DVPMG) of January 2021, the emergency medical service (CALL 116117) was granted the option of video conferencing for assistance, especially in more sparsely populated regions. For technical simplification, patients and doctors are to receive digital identities that allow authentication independently of the electronic health card (eGK) or the electronic health professional card (eHBA).

The ”Gesetz für sichere digitale Kommunikation und Anwendungen im Gesundheits­wesen“ (Secure Digital Communications and Applications in Health Care Act, also called ”E-Health Act“) of May 2015 was passed to introduce ”Digitale Gesundheits­anwendungen“ (Digital health applications, DiGA) and establish the various features of the telematics infrastructure (TI). The declared goal is to improve ”economic efficiency, quality and transparency“. The law contains a fixed timetable for the introduction of emergency data management (NFDM), the electronic medication list (eMP) and protected transmission protocols (later referred to as KIM). The Qualified Electronic Signature QES was established. Telemedical applications such as video consultation were to be facilitated. In addition, the foundations were laid for the further development of the TI and its use by non-medical professions such as therapists or nurses.

The ”Termin­service- und Versorgungs­gesetz“ (Appointment Service and Care Act, TSVG) of May 2019 was introduced for shortening the waiting time for appointments in medical practices. In addition, it obliges the statutory health insurance companies (GKV) to offer electronic patient files (ePA) and access to them via smartphone or tablet computer, even without the electronic health card (eGK). In addition, ”electronic certificate of incapacity for work“ (eAU) may only be sent digitally to the GKV.

The ”Digitale-Versorgung-Gesetz“ (Digital Health Care Act, DVG, also known as ”E-Health Act II“) of December 2019 regulates the introduction of ”Digitale Gesundheits­anwendungen“ (Digital health applications, DiGA). It also obliges pharmacies and hospitals to connect to the telematics infrastructure (TI). The connection of midwives, physiotherapists, nursing and rehabilitation facilities remained voluntary. New standards for digital interfaces were defined to improve data networking in the health sector. The regulations on electronic patient files (ePA) were explicitly excluded and were defined in the ”Patienten­daten­schutz­gesetz“ (Patient Data Protection Act, PDSG, see below).

The ”Patienten­daten­schutz­gesetz“ (Patient Data Protection Act, PDSG) of October 2020 lays the explicit foundations for the use of the electronic patient record (ePA) with regard to its contents and access rights. Patient sovereignty is intended to ensure that patients have a right to the ePA but no obligation, that the ePA is to be managed by the insured person himself/herself, that he/she decides from the outset which data is to be stored, who may access it and whether data is to be deleted again. Accessibility must be ensured. Insured persons should be allowed to release their data for research purposes. Only from 2022 onwards, a ”finely granulated“ authorisation management on document level or categories of documents or categories of medical specialties shall be mandatory. Data security is to be guaranteed by the telematics infrastructure (TI). In addition, the introduction of electronic prescription (”eRezept“) and electronic referral (”eÜberweisung“) is determined. From 2022, it should also be possible to store vaccination cards, maternity cards, ”U-Heft"“ (documentation booklet of examinations for children) or dentist bonus booklets in the ePA. Patients will have full access to their ePA via an application on their smartphone or tablet computer and will also be able to enter their own data (such as blood pressure or blood sugar measurements).

The ”Digitale–Versorgung–und–Pflege–Modernisierungs–Gesetz“ (Digital Nursing Care Modernisation Act, DVPMG) of January 2021 introduces ”Digitale Pflege­anwendungen“ (digital applications for nursing, DiPA). These are ”smartphone applications“ for nurses to help documentation (e. g. falls), trainings/exercises (e. g. balance exercises or memory games) for patients. The nursing care insurance funds are supposed to cover the costs. So-called ”Digitale Gesundheits­anwendungen“ (digital health applications, DiGA; not to be confused with DiPA) are already available. Patients are supposed to use these ”smartphone applications“ themselves to do exercises or self-assessments in the context of their illnesses. According to the new law, their data should be transferable to the electronic patient record (ePA). For this purpose, the DiGA should not only be checked by the ”Bundes­amt für Arznei­mittel und Medizin­produkte“ (Federal Office for Drugs and Medical Devices, BfArM), but also have to carry a ”certificate for information security“. Presumably due to experiences from the corona pandemic, the use of video consultations is to be facilitated. On the one hand, this will allow you to show your symptoms to the emergency medical service (CALL 116117) in a video conference. On the other hand, it offers the possibility to issue ”electronic certificate of incapacity for work“ (AU-Bescheinigungen) after a video consultation. For easier communication in the telematics infrastructure (TI), all participants are to receive a ”digital identity“, which is to be used for identification even without an electronic health card (eGK) or electronic health professional card (eHBA). The emergency data management (NFDM) and the electronic medication list (eMP) are now to be stored in the TI and no longer on the eGK, which will then no longer have its own storage capacity. New ”smartphone applications“ are to be developed for this purpose. An electronic organ donation declaration is also to be introduced with these apps. The electronic prescription (”eRezept“) application will be expanded so that prescriptions for nursing, physiotherapy or medical aids can also be filled. Therefore, other participants in the health care professions, such as nursing services or aid dealers, will also be obliged to connect to the TI. In addition, electronic prescriptions should be redeemable in other countries of the European Union (EU). For this purpose, an ”eHealth contact point“ is to be set up, which will also allow the exchange of health data with doctors in other EU countries.