Telemedicine Programmes in Germany: Legislation, Implementation and Scientific Considerations 

Telemedicine has increasingly become a fundamental component of healthcare delivery in Germany, addressing access challenges, supporting emergency services and facilitating continuity of care. The COVID-19 pandemic accelerated its adoption, particularly in outpatient settings, reproductive healthcare and chronic disease management. This following explores the legislative framework, implementation strategies, funding mechanisms and scientific findings associated with telemedicine in Germany.

Telemedicine services in Germany operate under a combination of federal and state-level regulations. Key legislative instruments include:

1. SGB V (Sozialgesetzbuch – Book V): Defines the statutory health insurance framework, determining which telemedicine services qualify for reimbursement.
2. E-Health Act (2015): Provides legal grounds for telemedical applications, including teleconsultations and digital prescriptions.
3. Digital Healthcare Act (DVG, 2019): Expands reimbursement eligibility for digital health applications (DiGA) and telemedicine consultations.
4. Ärztliche Berufsordnung (Medical Professional Code): Establishes rules for remote treatment, including the requirement that physicians ensure an adequate standard of care.
5. General Data Protection Regulation (GDPR): Ensures that telemedicine applications comply with EU-wide data privacy and security standards.
6. DiGA (Digitale Gesundheitsanwendungen) Pathway: Allows certain digital health applications to be reimbursed under statutory health insurance.
7. Selective Contracts (Selektivverträge): Allow regional health insurers to fund specific telemedicine services outside the standard statutory health insurance framework.

Telemedicine programmes in Germany are financed through multiple mechanisms:

• Statutory Health Insurance (GKV): Services covered under SGB V, such as teleconsultations and certain digital health applications (DiGA), are reimbursed by statutory insurers.
• Private Health Insurance (PKV): Many telemedicine services, including those not covered by statutory insurance, can be accessed through private health plans.
• Selective Contracts (Selektivverträge): Some telemedicine services, particularly specialist programmes, are funded through direct contracts between insurers and providers, bypassing standard reimbursement structures.
• Hospital-Based Funding: Telemedicine in emergency medical services and hospital settings is often funded directly by hospitals through internal budgets or regional healthcare grants, particularly in university hospitals and teaching hospitals where innovation is a priority.
• Public Health Initiatives & Grants: The German government, EU health programmes and regional health authorities provide funding for specific telemedicine pilot projects, such as Schwangerschaftsabbruch-zuhause.
• Employer and Occupational Health Programmes: Large employers sometimes contract telemedicine providers for workforce health management.
• Non-EBM (Einheitlicher Bewertungsmaßstab) Funding: Some telemedicine solutions that are not reimbursed under the outpatient billing system can still be integrated into hospital-specific budgets, regional initiatives or through private direct-pay models.
• University and Teaching Hospitals: Many telemedicine research initiatives originate in institutions such as Charité – Universitätsmedizin Berlin, University Hospital Heidelberg and LMU Klinikum Munich, where they receive state or federal research grants.
• Private Sector and Industry Partnerships: Pharmaceutical, MedTech, and digital health companies collaborate with healthcare providers to develop and fund telemedicine solutions.

Contracting of telemedicine services vary based on the provider and setting. In hospitals and EMS, telemedicine services are typically procured through public tenders or direct agreements with regional health authorities. Out-patient telemedicine services, including digital health apps and video consultations, are integrated into the EBM outpatient billing system but require contractual agreements between insurers and service providers. University hospitals often secure research grants to develop and trial telemedicine interventions before full-scale reimbursement is approved.

Germany has developed various telemedicine initiatives across multiple domains, including emergency medical services, chronic disease management and reproductive healthcare.

Emergency Medical Services (EMS)

The implementation of telemedicine in EMS has been a critical solution to address rising demand and workforce shortages. Projects such as Telenotarzt Aachen and ETHAN Houston-inspired models integrate telemedical physicians into ambulance services, enabling real-time communication between paramedics and emergency physicians. Studies indicate that such systems improve turnaround times, enhance triage and reduce unnecessary hospitalisations.  Key findings from the Telenotarzt Model Aachen include:

• A reduction in emergency physician dispatch rates, leading to cost savings.
• Enhanced patient outcomes due to early teleconsultation.
• Improved response times for severe cases requiring physician intervention.

Many of these EMS telemedicine services are regionally contracted and depend on state-specific funding initiatives rather than a unified national framework.

Chronic Disease Management

Telemonitoring and telecoaching have been effectively implemented in heart failure management. A retrospective, propensity-matched study in Germany involving 6065 heart failure patients demonstrated:

• A 47% reduction in all-cause mortality for patients enrolled in a telehealth programme compared to usual care.
• A significant decrease in hospitalisation rates (17.9 vs. 21.8 per 100 patient-years, p<0.001).
• Improved medication adherence and self-care behaviours.

Such programmes align with the European Society of Cardiology (ESC) guidelines, which recommend telemonitoring as an adjunct to standard heart failure treatment. University hospitals are often involved in implementing and evaluating these programmes, securing grants for research into cost-effectiveness and clinical outcomes.

Reproductive Healthcare: The Telemedicine Medical Abortion Programme

Berlin’s Schwangerschaftsabbruch-zuhause project, initiated by the Family Planning Center BALANCE, extends telemedicine services to women seeking medical abortion. Findings indicate that:

• 56% of patients at BALANCE opted for telemedical abortion services.
• 83% reported they would use the service again.
• 93.5% expressed a desire for its continuation beyond pandemic-related measures.

While statutory health insurers may cover some aspects of telemedical abortion services, much of the funding comes from regional government grants and private organisations due to regulatory restrictions on abortion services in Germany.

Despite its successes, telemedicine in Germany faces barriers related to reimbursement, physician licensing and regional disparities.

1. Reimbursement Gaps: Some services, such as digital therapeutics, are covered under DiGA regulations, while others lack structured financing within the EBM outpatient billing system.
2. State-Level Variability: Telemedicine regulations differ across federal states, creating inconsistencies in service availability.
3. Integration with Traditional Healthcare: Effective telemedicine requires coordination with in-person healthcare providers to prevent fragmentation of care.
4. Technological and Data Security Concerns: Ensuring compliance with GDPR and cybersecurity standards remains a priority.
5. Hospital-Specific Funding Challenges: Many teaching hospitals and university medical centre’s use pilot funding that does not always translate into long-term reimbursement sustainability.

Telemedicine in Germany has evolved from a supplementary tool to a critical component of healthcare delivery. Legislative support through the Digital Healthcare Act, integration into EMS and chronic disease management and initiatives like Schwangerschaftsabbruch-zuhause illustrate its potential. However, addressing reimbursement gaps, enhancing standardisation across states and ensuring equitable access remain essential to fully realise the benefits of digital health in Germany. Hospitals, particularly teaching and university hospitals, play a key role in piloting, funding and developing telemedicine solutions that shape future reimbursement policies.