"TI(Telematik Infrastructure) is a network dedicated to Healthcare within the German Healthcare system".
Everyone interacting with the German healthcare system and those seeking mechanisms to implement digitization of healthcare across a region or country will find this article very useful.
History of TI
The German government adopted 2004 a law to implement the eHealth card.
#gematik was founded in January 2005. It is the German central coordination and communication center for all topics related to telematics infrastructure and health cards.
In 2011, all the shareholders decided to rollout phase 1.
In 2013 the contract was awarded to the industry partners
CGM Clinical, Arvato Systems, T-Systems International, Atos, FAU(Friedrich-Aelxander Universitat Erlangen-Nuremburg).
On August 14th, 2014 agreed the Kassenärztliche Bundesvereinigung (KBV) and the GKV-Spitzenverband (GKV-SV) agreed, that as of January 1st, 2015, the old health card without chip and photograph will be invalid.
Since 2018, eHealth connectors and card terminals and connected to the telematics infrastructure (TI).
Since 1st July 2022 use of an electronic certificate of incapacity for work is functional.
And now slowly moving towards TI 2.0 which is introducing newer functionalities which will be discussed over the next course of our article.
What is TI
Trust and transparency are essential in any system, including those related to healthcare. With that in mind, Germany's Telematik infrastructure (TI) from Gematik gmbh is supported by the Federal Commissioner for Data Protection and Freedom of Information (BfDI) and the BSI (Federal Office for Information Security [Bundesamt für Sicherheit in der Informationstechnik]). This modernization drive gives fast availability, universal access, and efficient management which digitizes and automates the German Health system.
With the Telematik Infrastructure (TI), we can create a standardized approach to both access and store healthcare information in Germany. This is one of the first initiatives of its kind in multiple verticals, helping to digitize many manual workflows within healthcare and thus saving both time and cost. The TI consists of hardware and software solutions working together over a secure internet connection to connect different stakeholders, enabling them to leverage its core functionalities for standardized communication of health data - an essential requirement for the successful implementation of #khzg. There are two implementations of TI are available, TI 1.0 and TI 2.0.
What is the important offering of TI?
Let us understand some of the crucial offerings from TI to us as stakeholders in this network.
Kommunikation im Medizinwesen (KIM)- Communication in Medicine(KIM)
It's TI's way of transferring sensitive health data between institutions, sectors, and departments in a more efficient, fast, and, above all, secure manner. By using a KIM email address, findings and documents (e.g. doctor's letters, transfer documentation, cash register information) are securely encrypted. The data can only be accessed by the person to whom it has been sent.
eRezept/eLeistungsnachweis- e-prescription
The use of e-prescriptions drastically reduces the need for paper and allows for faster access to prescriptions; for doctors, pharmacists and patients alike. Approximately 500 million prescriptions are issued every year, and they no longer need to be in hard copy form. Also, nursing care is not involved with issuing prescriptions; rather, they simply take a digital proof of performance with them to the patient, where it can be certified with their signature. This results in fewer pieces of paper being used while also speeding up billing processes.
elektronischer Medikationsplan (eMP)-Electronic Medication Plan
More than 25% of all patients need more than three medications permanently due to a lack of coordination of information. Based on current studies, more than 25% of patients need more than three medications permanently. With the help of the electronic medical record, these people are entitled to create a nationwide medication plan (BMP), which can be digitally mapped. Furthermore, the eMP can be used to store information relevant to medication, such as allergies or intolerances, in addition to an overview of all medications currently taken.
elektronische Patientenakte (ePA)- Electronic Patient Record
Patients are able to view all their health-related data, documents and files in one place, with themselves deciding who sees which information and when. Patients with statutory health insurance receive an ePA from their insurance company via its app, which allows them to monitor existing content, delete it or add new material. Voluntarily, a person can also store other applications such as an electronic medication plan (eMP) or emergency data record (NFDM). As of 2022, expansion stage 2.0 is in the process, meaning that vaccination and mother's cards, dental bonus and child examination booklets can be saved too. For service providers, the ePA offers insight into the health data of patients prior to treatment; additionally, nursing documents like plans and recordings can be stored electronically for future use by other individuals.
TI-Messenger (TIM)
The TIM messenger service is the perfect communication medium for healthcare professionals in Germany! From Q2/2023, it will give all practitioners a quick and simple way to get in touch with each other. Medication queries, therapeutic advice, laboratory results and callback requests can all be sent via short messages in real time. Furthermore, a unified address book of certified providers across the nation makes locating contact details fast and easy.
What are the core principles of telematik infrastructure?
Gematik has set six core principles for a modern, streamlined and secure healthcare platform. These are the building blocks of a more user-friendly, agile and adaptive digital healthcare system in Germany, allowing for greater innovation, improved care, improved communication channels, simplified usability and increased autonomy for patients. The Gematik Directory Service (VZD) is a pivotal component of Telematics Infrastructure (TI), acting as the TI's secure index. Certificates and larger sets of data such as contact details of doctors, pharmacists, psychologists and other healthcare providers are securely stored on VZD, while it also manages all relevant technical information for Gematik applications.
Electronic Identity( Federated Identity Management)
Federated Identity management is the foundation of TI, providing various authentication mechanisms per user. In TI 1.0, this was done through smart cards (eGK, eHBA and SMC-B) whereas TI 2.0 uses electronic identities (eIDs). Gematik-approved identity providers are responsible for authenticating the users rather than the services themselves. This allows users to register only once with the identity provider and reap the benefits of a single sign-on to access all applications.
The universal Availability of Service through access interfaces on the internet
TI offers services like ePA, KIM, and TIM that can be accessed through personal devices, without having to rely on a TI connector. To use the ePA app for healthcare insurance, it's possible to download it from the Apple App Store or Google Play Store onto a smartphone or tablet. With an electronic health card or two-factor authentication, users are able to log into the ePA app to view data and upload/download documents. Institutions that want to access the electronic patient file need to connect with the telematics infrastructure using a PTV4 connector and an eHealth card terminal. An SMC-B institution card is also required for authentication within TI.
State Art Modern Security Architecture
A closed network is crucial for security, so TI has introduced "Zero Trust networking" in TI 2.0 as part of its architecture. The user authenticates themselves using smart cards or eIDs, and once authenticated, they can access all TI services through the internet. This is an important improvement over TI 1.0 where users were required to authenticate using connectors and routers.
Distributed Service
TI 2.0 facilitates the development of applications that are built on combining various services. Through standardized interface technologies and unified data formats, data and processes from those individual services can be accessed in two ways: through the user's app or by directly linking those services together. This provides patients with the opportunity to share their information with their care providers without having to rely on a single source of service.
Interoperability and Structured Data
FHIR (Fast Healthcare Interoperability Resources) serves as the overarching standard for data structures and interfaces in TI 2.0. It is based on clinical practice, is internationally utilized, and has been designed to promote interoperable data exchange across all types of healthcare documentation. This enables maximum flexibility when it comes to selecting and restructuring documents and data according to application - a necessity for cross-service or cross-application integration. Furthermore, FHIR's use helps improve data quality and encourages international implementation. Other approaches, such as MIO (Medical Information Objects) and ISIK, focus on the standardization of transfer and types of data that meet international healthcare standards.
Common TI rules
In TI 2.0, minimum standards are established by a set of legal, organizational, and technical rules that form its security architecture; this is developed and implemented in tandem with gematik GmbH by the relevant sector bodies (e.g. the National Association of Statutory Health Insurance Physicians, German Hospital Society) to regulate security, data protection, functionality, interoperability, and availability. Moreover, parts of the set are machine-readable to allow systems and components of the TI to check adherence automatically.
Who are the stakeholders and how do they benefit from it?
Patients
Empowering patients and granting them control of their data is key. To ensure a clear overview, they can provide electronic patient records to their healthcare providers, ensuring specialized treatments like those of doctors, dentists, psychotherapists or pharmacists are up to date. Some data can only be changed with the patient's own consent. Additionally, the electronic health insurance card (eGK) of lawful insured individuals can be used for authentication within TI systems. With the help of VSDM (Insured Master Data Management), the need for issuing new cards every time the address or insurance status changes is eliminated as data updates are automatically initiated during each doctor's visit once changes have been already reported to health insurance funds.
Insurance companies
Source of trusted data that health insurance companies can use to verify insurance and treatment claims. This is a very effective method of increasing transparency in the insurance industry.
Doctors
The electronic patient record (ePA) is one of the most important applications of the TI. Through the ePA, every individual with statutory health insurance can access their patient file on the move. Through KIM, doctors can send messages between They can also send medical records, emails or other messages Through TIM, doctors can send medical records, emails, or other messages. They can also view treatments already performed and investigation findings.
Nurse
The communication between the care providers and professionals became more standardized. This will help them communicate in case of emergencies as well as consultations.
Pharmacists
In case of any clarifications, pharmacists are provided with an opportunity to communicate with care providers through e-prescriptions.
psychotherapist
Using ePA, they will be able to access patient data easily. This will be very beneficial for their therapy, and KIM and TIM will help them to resolve their clarifications with other experts in the same field.
How to implement TI in your facility?
For that, you need to be acquiring or cooperating with service providers who have "on-site service provider" (DVO) certification from Gematik. You should also focus on making the following functionalities available to TI members.
TI infrastructure implementation needs a detailed technical understanding of the internals of TI to get better implementations.
And ePA is dependent on the distributed ledger technology to provide distributed user authentication.
Let's understand each of the Functionalities and their relevant technologies.
Legally defined interfaces according to ISiK
If your device is a “confirmation-relevant system,” it must have an interface that follows, e.g., the ISiK Basic Module specification.
Structured data sets for MIOs
Manufacturers must be able to exchange medical information objects (MIOs) in order to write or access data in electronic patient records (ePAs).
IT systems in healthcare
The manufacturers of other IT systems, including digital health applications (DiGA) and hospital and primary care practice management systems, are no longer free to choose their own interoperability standards.
Implants and disability aids
Implants or disability aids that transmit data must also communicate with digital health applications via standardized interfaces.
Communications standards for KIM and TIM
Manufacturers should enable TIM and KIM communication not because of the law, but because it is being demanded by customers (hospitals, doctors' practices). KIM is dependent on Matrix protocol.
You can access the TI test Suite for your evaluation and test the application's build.
Get more details in application releases
Major TI implementors
AKQUINET A major TI implementation partner for many organizations including one of the notable patient portal providers like m.Doc GmbH.
CGM Clinical A major TI implementation provider and partner who is involved in TI from the beginning and is acting as a partner historically.
Arvato Systems is Another TI partner that is working on TI for more than 8 years and is very well associated to provide various services of TI to the corresponding users.
Current challenges in TI
TI got off to a late start but has started gaining momentum and is gradually developing. Despite being set in motion at least 15 years ago, more organizations need to join forces in order to expedite activities and make it an even more unified effort. The application of AI has yet to enter the picture; if it does it could greatly enhance aspects of healthcare connectivity and standardization, bringing efficiency and effectiveness. There are very few service providers offering limited customized services in both KIM and TIM.
Takeaway from Telematik Infrastructure
The various merits of TI technology include relief for nursing staff in their everyday operations, which also results in higher job satisfaction for them. In addition, patient care is improved thanks to a shared, visible database. Furthermore, efficiency is increased through the use of electronic patient files and regularly updated medication plans that can be accessed from the patient's site. This further allows for faster communication with external services and more time spent with patients. Lastly, improved dismissal and transfer management as well as faster billing with nursing care funds are enabled by TI while data security and protection are certified through gematik GmbH- all without additional expenses for the care facility from GKV refinancing agreements.
A great step towards digital health, a lesson for the world to understand and implement. In case of queries, please comment or revert.
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