How digital is the German outpatient healthcare system? A review on past and future measures, challenges and opportunities

Background The introduction of the electronic health card in 2015 marked the start of the German Telematic Infrastructure (TI), a nation-wide e-health infrastructure aimed at digitally connecting healthcare providers, insurers, and patients within the statutory health insurance system. The expansion of the TI within the German healthcare system is progressing but still slow by international comparison. The German government seeks to incrementally enhance this infrastructure to align with the demands of the digital age, thus creating new opportunities for patients and service providers. In this literature review, we critically examined the current status of the TI in Germany, focusing on the implemented and planned measures, challenges encountered, and opportunities available for providers and insured individuals to help inform stakeholders in the field. Methods A comprehensive literature search was conducted across PubMed, Journal of Medical Internet Research, relevant governmental websites, and the library catalogues of the Technical University of Munich and Ludwig-Maximilian-University Munich. The review included both qualitative and quantitative studies, as well as governmental publications and internet sources from gematik GmbH and other providers. Results The analysis indicates that TI elements are increasingly integrated into routine care within medical facilities, but Germany lags behind in international comparisons. Despite Germany's leading role in certifying and distributing digital health applications, their utilisation remains far from optimal especially for prevention purposes for which they are currently not licensed. The deployment of new digital health services and national-wide rollout of TI applications is particularly hindered by technical, financial, and organisational challenges affecting service providers, patients, and key stakeholders such as statutory health insurance companies. Nevertheless, the digital health infrastructure offers clear benefits, including improved healthcare delivery, as well as time and cost savings. Conclusion Germany remains significantly behind other nations in developing a comprehensive digital health infrastructure. To address this lag and the associated challenges, further initiatives, such as the 2025 introduced nationwide implementation of the electronic patient record with an opt-out option, are crucial. However, significant work remains, particularly in enhancing training and education for both healthcare professionals and patients, overcoming technical challenges and addressing the unfavourable cost-benefit ratio.