1
45
6 (Un-)Familiarity with
the Telematics Infra-
structure Prior to Its Man-
datory Implementation:
A Qualitative Study Among
Home-Care Nursing Ser-
vices in Germany
Sauter, Stefanie 1*
Nordmann, Kim 1*
Redlich, Marie-Christin 1
Möbius-Lerch, Patricia 1
Schaller, Michael 1
Fischer, Florian 1
1 Bavarian Research Center for Digital Health and Social Care,
Kempten University of Applied Sciences
* These authors contributed equally
ORCID:
Sauter, Stefanie: 0000-0001-6339-6506
Nordmann, Kim: 0000-0003-2211-9603
Redlich, Marie-Christin: 0000-0002-2973-5743
Möbius-Lerch, Patricia: 0000-0001-8969-400X
Schaller, Michael: 0000-0002-1149-9252
Fischer, Florian: 0000-0002-4388-1245
46
6Background
This article discusses the mandatory introduction of the telemat-
ics infrastructure (TI) in the German health system and explores the
knowledge and experiences of home-care nursing services with the TI.
Collaboration between health professions is necessary to adequately
meet the complex health and nursing care needs within in ageing soci-
ety. However, interprofessional teams need corresponding structures
and instruments for promoting (or even enabling) efficient and effective
communication as well as collaboration processes (Karam et al. 2018).
In this context, the telematics infrastructure (TI) is to be mandatorily
introduced as a digital platform to ensure secure and fast communica-
tion and data transmission in the German health system. Easy access
and interoperability should herein enable organisationally and socially
sustainable and cooperative health care (Andelfinger and Hänisch, eds.
2016). The aim of the nationwide implementation of the TI is to enable
faster and more accessible exchange of information and health records
between healthcare professionals through a standardized system which
is compliant with data protection rules and, thereby, to increase patient
safety. However, the implementation process has been characterized
by numerous challenges and resulting delays – and even though the
implementation has recently made progress, the whole process is still
slow (Lau 2022; Maybaum 2017). Despite 89% of physicians in outpa-
tient care having been connected to the TI by the end of 2021 and value
the digitalisations potential, only few use it (Stachwitz and Debatin
2023; Albrecht et al. 2023). Evaluation results of the equipment phase
show low acceptance and practical suitability among medical facilities –
with the exception of the Communication in Medicine (Kommunikation
im Medizinwesen [KIM]) service, which makes it possible to transmit
all kinds of secure and encrypted messages via the TI. In addition to
(perceived) technical difficulties, significant information and training
deficit became obvious (der Heiden et al. 2021). In particular, the lack of
connection of non-medical communication partners, such as nurs-
ing services, pose challenges towards the widespread usage of the TI
(Stachwitz and Debatin 2023; Albrecht et al. 2023).
Since 2021, home-care nursing services were able to
introduce the TI on a voluntary basis. Originally, it was supposed to
be mandatory from January 2024 onwards. However, at the end of May
2023, this mandatory implementation was postponed to July 2025 due to
the regulations in the Care Support and Relief Act (Pflegeunterstützu-
ngs- und Entlastungsgesetz [PUEG]), for services according to the Ger-
man Social Code Book XI (Sozialgesetzbuch [SGB] XI), which contains
the regulations for social long-term care insurance in Germany.
47
6Until now, studies in the context of TI implementation in Germany
have mainly focussed on medical care providers. Therefore, this con-
tribution aims to describe home-care nursing services’ knowledge of
and connection to the TI, their experiences and expectations with it.
Methods
As part of a research project at the Bavarian Research Center for
Digital Health and Social Care, expert interviews on digital inter-
professional communication and cooperation were conducted with
employees of home-care nursing services in a city and its surrounding
area in southern Germany from April to July 2023. The interviews took
place either at the participants’ workplace, in the interviewers’ office
or online via a video conference tool, according to the participants’
choice. The semi-structured interviews were based on an interview
guide and included questions about participants’ knowledge of the TI
as well as their experiences and expectations. After the interviews,
the participants answered a short socio-demographic questionnaire.
Ten professionals (six female and four male) from different home-
care nursing services were interviewed (mean age 44±11 years). Of the
interviewees, nine were care service managers or deputy care service
managers, and one person was acting as a nursing professional. One
person was self-employed, while all the other interviewees were either
employed by relatively small home-care nursing care services or larger
companies with branches all over Germany.
The interviews were analysed using thematic analy-
sis according to Braun and Clarke in MAXQDA version 22 (Braun and
Clarke 2006). For the purpose of this extended abstract, only a sub-
set from the larger study assessing interprofessional communication
between home-care nursing services and general practitioners is
presented, focusing on the current knowledge and connection status
among home-care nursing services.
Results
The results presented reflect the current knowledge of the telematics
infrastructure as well at the connection status. Quotes from the inter-
views were pseudonymized (P01 – P10) and translated from German
into English for the purpose of this contribution.
48
6Knowledge of telematics infrastructure
The knowledge of people employed at home-care nursing services –
and mostly even responsible for the management of these facilities –
about the TI is heterogeneous. Apart from one person who works in
a small home-care nursing service, the respondents have little to no
knowledge about the mandatory introduction of the TI in the near
future and its potential benefits for home-care nursing services.
“Telematics infrastructure? Doesn’t tell me anything.
What does this mean?” (P08)
“[The telematics infrastructure is] probably already an
advancement in communication, by telephone or what-
ever, that something is being developed. But otherwise, I
have no idea.” (P03)
Telematics infrastructure connection status
All home-care nursing services use, or are currently in the process of
introducing, digital software for internal purposes such as planning
tours for care staff, communication between team members and care
documentation.
“We do everything with it [the software]. Our entire plan-
ning, our entire client data is stored there. [...] And we
have a message portal where I can write a message to the
caregiver.” (P03)
However, none of the home-care nursing services are connected to
the TI yet, and most of them are unaware about funding opportunities
which may support the implementation within their facility.
“I haven’t really got to grips with that yet. This is a cur-
rent topic for us, this telematics infrastructure. [...] But
at the moment, it’s more an area that IT is taking over for
us. And we are not quite involved at the moment.” (P06)
“From time to time, initial information came in, but it is
never concrete that one has said: ‘We’ll connect here’ or
‘We’ll change over’. No. No.” (P08)
One person is fully aware of the funding options for TI and is already
in the process of implementing it in their home-care nursing service.
49
6“Yes, I have now purchased seven new smartphones and
also this hardware for the telematics infrastructure,
which I also had to buy. Everything has already been
bought [...] in the end, if you search for five minutes, you
will find the funding and it is really easy. You submit it
and it’s really: You submit the invoice; you submit the ap-
plication and it’s in your account three weeks later. So, it
wasn’t this act now, this effort that I was afraid of.” (P01)
Yet, home-care nursing services would like to receive more informa-
tion and training regarding the introduction of the TI and the trainings
should be straight forward and practice orientated.
“We simply need more knowledge about telematics. [...]
Everyone has half-knowledge, and we first have to put
ourselves in a state that enables us to somehow judge this
in a competent way to some extent, so that we can then
also use it properly.” (P05)
“It is usually the case, I made the experience that all the
training courses I have done so far have never been very
practice-oriented.” (P01)
Expectations and concerns
After explanation of the TI to the participants, the home-care nursing
services have largely positive attitudes towards its nationwide imple-
mentation. Many are in favour of the mandatory usage and hope for an
improvement in communication with other health care professionals,
while some are sceptical about the introduction due to the associated
costs and the lack of visible benefits for them. Many home-care nurs-
ing services hope that the TI will give them a better insight into the
patients’ conditions and improve their care. For example, some would
like the TI to automatically inform them of changes in the patient’s
medical plan and provide a secure channel for information exchange.
Above all, improved communication played a major role for all respon-
dents. They hope that the nationwide utilization of the TI will lead to a
communication among diverse actors in the health care system which
is more structured, uniform, faster and less prone to errors.
“It could all be simplified. Maybe fewer conversations,
fewer pieces of paper, less transfer of information from
employee to employee or from shift to shift. [...] And the
50
6sources of error would be significantly reduced, I would
say. So not only within the service, but of course also in
the communication GP/outpatient service.” (P08)
However, many of the home-care nursing services fear additional
work due to the mandatory implementation of the TI. They expect
an easy-to-use, functional TI. Since all home-care nursing services
already have individual digitally supported solutions, it would be
desirable if the TI could be integrated into these existing systems and
processes.
“That it [the telematics infrastructure] is easy to use,
that it is not too complicated, that you can quickly famil-
iarise yourself with it and that it is easy to integrate into
the system.” (P06)
“It’s not like I can train to be an IT person. And yes, the
system should just be simplified and more direct, the
communication.” (P02)
Some respondents fear complications in the introduction and use of
the TI, as was the case in the implementation of earlier projects. They
experienced that many mandatory introductions were not adapted to
the necessities of home-care nursing services and are unnecessarily
complicated.
“I’ve been applying for an electronic health profession
card since last week. I applied for it and did the Post ID
yesterday, you must have studied almost twice to be able
to do it all at once. It’s phenomenal how difficult some-
thing like that can be.” (P07)
Discussion
The results indicate that home-care nursing services are insufficiently
informed about the TI, albeit some being more informed than oth-
ers depending, amongst other factors, on their willingness to inform
themselves and the organisational structures of the home-care nurs-
ing service. Some participants are employed at larger nursing services
with a specialized IT department and thus are not required to conduct
acquisition and preparations for the introduction of the TI. The only
person that was well informed about the TI and already started imple-
51
6menting it in her home-care nursing service, was a professional from
a smaller service. This person was also self-employed and running her
own home-care service, and as such might have been more on top of
current changes and funding opportunities than employees of larger
home-care services who are not involved in such processes.
After the explanation of the TI and its various compo-
nents by the interviewer, there was a notable openness towards the
implementation of the TI among the representatives of the home-care
nursing services. Above all, they hope for improved interprofessional
communication through the TI connection, since communication via
fax and telephone is perceived as laborious and time-consuming. A
study conducted in Austria assessing the implementation of the Aus-
trian electronic health record (ELGA) in nursing homes reported that
nursing care managers anticipated an electronic health record would
improve information flow and exchange of patient related information
and also assure completeness and actuality of patient data (Schaller et
al. 2020). This is in line with our findings, indicating that home-care
nursing services hope that the TI will provide better insights into the
patients’ conditions, assure the actuality of medication plans and thus
improve the processes and quality of care.
Ease of use and facilitation of work processes, as well
as a clear understanding of the benefits of the innovation by its users
are some of the most important factors for the implementation of
health information and communication technologies (ICT), such as
the TI (Gagnon et al. 2012). The results of this study point towards a
greater need for improvement in education and training related to the
implementation of the TI. Interviewees of home-care nursing services
have very high hopes in the TI. However, most home-care nursing
services are at their capacity limits and are afraid that they have to
cope with complex applications and IT problems when putting the TI
into operation. This is also reflected in a review of factors influencing
the adoption of ICTs by healthcare professionals (Gagnon et al. 2012).
Here, technical concerns were one of the most frequently mentioned
barriers for a successful implementation of ICTs. Furthermore, the
interoperability with existing systems and processes was an important
factor for the adoption of new systems (Gagnon et al. 2012). This is also
reflected in our study. As all of the interviewed home-care nursing
services already use their own software, the care managers were afraid
that the TI will not be compatible with their existing systems and
cause them more work than actual benefits. To ensure a successful
implementation and long-term utilization of the TI, it is necessary on
the one hand to involve the home-care nursing services in the process
of further development and on the other hand to limit unnecessary
52
6extra work which might be associated with the conversion to a new
digital system. Therefore, the postponement of the mandatory imple-
mentation of the TI at home-care nursing services to mid-2025 needs
to used optimally: Particularly actors from the nursing practice and
management of these facilities need to be involved and prepared to
ensure a smooth implementation phase and enable that the full poten-
tial of the TI is unfolded.
It has to be mentioned that the presented results are
a subset from a larger study, assessing interprofessional communica-
tion between home-care nursing services and general practitioners.
However, in light of the upcoming mandatory use of the TI also among
home-care nursing services, the presented results purposefully fo-
cused on the current knowledge and connection status among this
subgroup. One might consider that only people with a general interest
in the topic (either related to digitalisation and/or interprofession-
al collaboration) participated in the interviews. As such the results
presented might not allow generalizability. Further we are well aware
that there are other health care professionals involved in the success-
ful implementation of the TI such as pharmacists and further therapy
professions. Therefore, future studies might include other health care
professionals in further regions in Germany.
53
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