TI Overhaul: Gematik plans centralization and more power for itself

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The Telematics Infrastructure (TI) of the German healthcare system should have been modernized long ago. As early as 2021, Gematik announced that it would replace connectors and electronic health cards by 2025. That didn't happen, as revealed by a confidential strategy paper that reads like a master plan for a second attempt. Gematik criticizes TI 1.0 in it: too complex, too prone to failure, too slow. The organization, which has been responsible for the system for years, is now using self-criticism as a justification for significantly more power in the future.

The 72-page document “Concept TI Operational Stability and Transformation Plan 2030,” dated May 8, 2026, was prepared by an internal task force under the leadership of Gematik's management and is classified as “confidential – TI Committee.” The Gematik shareholders' meeting is scheduled to vote on its implementation on June 19.

Disruption Situation as a Trigger

The paper describes the current state of the TI in clear terms. In 2025, the use of TI applications was impaired on average 25 times per month. 162 disruptions alone affected the electronic patient record (ePA), 164 the e-prescription. Gematik attributes this not to individual errors, but to the architecture itself: Over 800 technical dependencies between TI products mean that the overall availability when redeeming e-prescriptions via electronic health card is mathematically only 97.975 percent – which mathematically corresponds to around seven days of downtime per year. This is despite the fact that the individual services involved achieve availability of 99 to 99.99 percent. In addition, known errors in the current system take one to three years to be resolved through the specification and approval process.

Centralization instead of Market Model

As a solution, the paper proposes switching from the decentralized market model to a central TI platform based on sovereign public cloud infrastructure. According to the so-called uniqueness principle, each backend function will only be implemented and operated once in the future. The number of backend product instances is to be reduced from the current 114 to 31. TI 1.0 with connectors, card terminals, and the proprietary VPN network is to be completely dismantled by the end of 2030.

Gematik Wants End-to-End Responsibility

The core of the proposal is a far-reaching change in Gematik's role: Instead of acting as a specification and approval authority, it is to control all contractual relationships in the future, commission operators directly, and assume end-to-end responsibility for the availability and security of the entire TI. The central ePA record system is to be centrally developed and operated under Gematik's responsibility as an open-source solution on the common cloud platform. Health insurance companies, which have so far controlled their own ePA backends, would thus hand over central parts of the previous backend operations to the platform.

The recommendation comes from Gematik itself. The document admits that the organization needs capabilities for the new role that it does not fully possess today and that the transition phase will initially create more complexity.

Stage Technology or General Manager?

At the DMEA Health IT trade fair in April, Gematik CEO Florian Fuhrmann described his organization's role with a metaphor: Gematik is “the stage technology,” invisible, behind the scenes. It doesn't decide what is played but ensures that the interplay is possible at all. He initially included the idea that Gematik is the conductor as a provocation – only to deny it all the more emphatically: “We are neither conductor nor conductor; we are not general managers; we are not a musician.”

Nevertheless, the strategy paper describes Gematik more in a general manager role: as an organization that controls all contractual relationships, manages all payment flows, commissions operators directly, bears responsibility, and is equipped with self-appointment rights. Gematik does not intend to dictate what is played, i.e., which apps doctors use or how medical processes run. The frontend will remain left to the market.

The paper outlines a three-phase timeline. By the end of 2026, the legal, regulatory, and organizational prerequisites are to be created, including any necessary legislative changes. The actual implementation begins in 2027: The cloud infrastructure will be put out to tender and built, and the first applications will be migrated. A new e-prescription backend is scheduled to go live on the new platform on September 1, 2028, along with the electronic referral. The electronic patient record is planned for Q4 2029, and the new unified communication service, which will replace the KIM email service and the TIM TI messenger, in Q1 2030.

However, the overhaul is not yet complete. The central TI 1.0 services are currently operated by Arvato. The document provides for three successive contract extensions, each with a reduced scope of services. The last extension is therefore valid until early 2032. Only then will the supposedly last servers of the old telematics infrastructure be switched off.

Vote on June 19

On June 19, the shareholders' meeting will convene with representatives from the Federal Ministry of Health, the National Association of Statutory Health Insurance Funds, the National Association of Statutory Health Insurance Physicians, the German Hospital Association, and other stakeholders. Several questions are on the table, such as whether Gematik should centrally develop and operate the ePA record system and whether it should build a unified communication service. The paper does not provide specific figures. The investment costs for building the platform by 2030 will be higher than the status quo, according to the document, but the ongoing costs in the stabilized state will be significantly lower.

(mack)