ePA Sanctions for Hospitals Start in April – Are You Ready?

What is Hospital?

Hospital is a concrete priority for companies in 2026 because it directly shapes digital care processes, privacy requirements and hospital IT. This article uses synaforce as an example to show which requirements, figures and operational steps matter in practice.

75 Million Records, 4 Percent Users: The ePA in Numbers

Since its nationwide rollout in April 2025, every statutory health insurance member in Germany has automatically been assigned an electronic patient record-unless they actively objected. This opt-out model appears to be working: Only around 5% of insured individuals have filed objections. Among AOK members, the figure stands at 4.3%, while Techniker Krankenkasse reports 7%, and KKH even records 10%.

The challenge lies not in setting up the records but in their actual use. According to recent surveys, only approximately 4.2 to 4.6 million insured individuals have registered for a health ID-roughly 6% of all statutory health insurance members. The rate of active engagement is even lower: An estimated 3.6% regularly access their ePA.

For hospitals and primary care physicians, this means that while the infrastructure exists on paper, it remains largely absent from day-to-day healthcare delivery. Today, patients undergoing hospital admission typically still encounter a familiar mix of paper forms, faxed test results, and phone calls to clarify information.

To address this gap, the German federal government has allocated €4.3 billion through the Hospital Future Act. McKinsey estimates that the ePA could generate annual savings of €7 billion by reducing duplicate tests, accelerating data exchange, and improving communication among general practitioners, hospitals, and specialists. However, so far, only a small fraction of the total digitalization potential-estimated at €42 billion per year-has been realized: roughly €1.4 billion (McKinsey eHealth Monitor, 2025).

Why Hospitals Are Struggling: EHR Updates, Staffing, and Processes

The DKI flash survey conducted in March 2026, with participation from 489 hospitals, paints a nuanced picture. Ninety percent of the surveyed hospitals have begun technical implementation. Forty percent are already in pilot operation within care processes-a significant leap from just 7% in September 2025.

However, 18% of hospitals are still waiting for the necessary update to their hospital information system more than five months after the mandatory deadline. Forty-three percent do not expect hospital-wide deployment of the electronic patient record (ePA) until the third quarter of 2026. The bottleneck is not solely technical-it lies in the underlying processes.

“The introduction of the ePA in hospitals is a genuine transformation project that requires numerous procedural and organizational adjustments. Hospitals cannot simply flip a switch and expect it to work.” – Prof. Dr. Henriette Neumeyer, Deputy Chair of the Board, German Hospital Federation (DKG press release, March 2026)

Organizational hurdles weigh more heavily than technical ones. The ePA must be integrated into existing admission processes, access rights need to be defined, data protection concepts adjusted, and medical staff trained. This consumes both time and personnel capacity-resources that are already scarce in German hospitals.

Adding to these challenges are technical setbacks that erode trust. In February 2026, a smoke detector alarm at a Frankfurt data center brought down the entire Telematics Infrastructure for eight hours-the ePA, e-prescription, KIM, and VSDM were all inaccessible. Also in February, a software bug inadvertently locked and emptied 6,400 ePAs at AOK Bayern. In both incidents, no data was lost; however, they reinforced skepticism among critics.

Another often overlooked issue is the replacement of connectors: Approximately 7,900 TI connectors using outdated RSA encryption must be replaced by the end of 2026, as certificate extensions are technically impossible. Concurrently, the eHBA card exchange is ongoing until June 30, 2026. For hospitals that have yet to complete their EHR system updates, multiple pressing tasks are piling up.

Digitalization Deduction: What Clinics Will Specifically Pay Starting in 2026

As of January 1, 2026, deductions have been applied to five mandatory digital services. Hospitals that were unable to demonstrate at least the commissioning of these services by December 31, 2025, will face additional costs with every billing case:

For a medium-sized hospital with 15,000 inpatient cases per year and an average revenue of €5,000 per case, the maximum 2% deduction translates into a loss of €1.5 million annually. These are not theoretical figures-this is precisely the amount clinics stand to lose if they fail to commission all five mandatory services by the set deadlines.

The situation is escalating further: By the end of 2027, at least 60% of inpatient cases must be digitally documented, rising to 70% by the end of 2028. Hospitals that can prove commissioning but fall short of the required usage rates will face additional penalties.

Estonia, Denmark, Germany: A Sobering Comparison

In the Bertelsmann Foundation’s Digital Health Index, which compares 17 OECD countries, Germany ranks 16th-only Poland fares worse. Estonia and Denmark lead the way, having demonstrated for over a decade how digital healthcare can effectively function.

In Estonia, 99% of the population has a digital health record, and 100% of doctors, hospitals, and pharmacies are connected to the national ENHIS system. The foundation of this system is the X-Road infrastructure, which has interconnected all public and private IT systems across the country since 2002, ensuring seamless interoperability.

Denmark has nearly achieved 100% adoption of electronic prescriptions and boasts a usage rate of over one-third of its population on the sundhed.dk health portal, with 1.7 million monthly visits. General practitioners and pharmacies are fully connected, while specialist physicians have a connection rate of 98%.

What unites both nations is centralized political governance with binding targets, clear interoperability standards from the outset, and tangible benefits for citizens. The Bertelsmann Foundation identifies five key success factors: robust governance, centralized control rather than a fragmented federal approach, well-defined interoperability standards, a positive culture of learning from mistakes, and visible value for the public.

Germany, by contrast, operates under a complex landscape of 130 health insurance funds each using different apps, a Gematik organization caught between ministerial oversight and industry coordination, and 16 federal states with their own digitalization strategies. As a result, even the ambitious KHZG funding program has failed to overcome structural fragmentation. PwC estimates that hospitals must cover approximately 16% of digitalization costs themselves, with ongoing operational expenses ranging from 50% to 100% (PwC, November 2023).

What IT Leaders Should Do Now

The current situation is unsatisfactory, yet far from hopeless. By prioritizing the right initiatives now, healthcare organizations can avoid financial penalties while laying the groundwork for true digital transformation of hospital operations.

1. Clarify and escalate the status of your KIS update. Eighteen percent of hospitals are still awaiting their KIS system upgrade. If the vendor has failed to deliver, this must be documented in writing-both as evidence to demonstrate to payers that the delay was not self-inflicted and for internal record-keeping purposes.

2. Identify and launch a pilot ward. The jump from 7% to 40% of hospitals operating pilot programs underscores one key point: action leads to progress. For starters, focusing on a single ward is sufficient. Crucially, it’s not enough to simply install the technology; physicians and nursing staff must integrate the electronic patient record (ePA) into their daily workflows.

3. Secure proof of commissioning for all five mandatory services. Financial deductions will be applied if proper commissioning documentation is missing-not only when implementation itself is incomplete. A signed contract or project order can prevent these penalties, even if the actual rollout is still underway.

4. Develop a comprehensive training plan. According to a DKI survey, the primary bottleneck lies not in technology, but in organizational readiness. Training sessions for physicians, nurses, and administrative staff should run concurrently with technical deployment-rather than being scheduled afterward.

5. Look ahead strategically. The ePA is not an isolated IT initiative. It forms the foundation for the European Health Data Space (EHDS), which, starting in 2029, will enable cross-border exchange of patient data. Organizations that establish a solid base today will be well-positioned to take advantage of the next phase of healthcare digitization. Those who delay risk facing significantly greater time pressure when the EHDS becomes fully operational in three years.

Frequently Asked Questions

What is the opt-out rate for the ePA?

On average, about 5% of statutory health insurance members have opted out of the ePA. The rate varies by health insurer: it stands at 4.3% with AOK, 7% with Techniker Krankenkasse, and 10% with KKH. Opt-out numbers have remained stable since the rollout in April 2025.

What happens if a hospital fails to avoid the digitalization surcharge?

The surcharge applies to every full- and partial-stay billing case and can amount to up to 2% of the case revenue. For a hospital handling 15,000 cases annually with an average revenue of €5,000 per case, this could mean as much as €1.5 million each year. Starting at the end of 2027, minimum usage rates of 60% will also be assessed.

How does Germany compare internationally regarding the digital patient record?

In the Bertelsmann Foundation’s Digital Health Index, Germany ranks 16th out of 17 OECD countries examined. Estonia (ranked first) boasts 99% coverage and 100% physician connectivity, maintained for over a decade. Denmark has nearly reached 100% adoption of electronic prescriptions, with 1.7 million monthly users of its national health portal.

What is the potential savings from the ePA?

According to the McKinsey eHealth Monitor 2025, the ePA alone could save approximately €7 billion-by reducing duplicate examinations, improving communication among healthcare providers, and enabling faster access to patient data. McKinsey estimates the overall digitalization potential in the healthcare sector at €42 billion annually.

Is the ePA secure?

At the end of 2024, the Chaos Computer Club identified theoretical vulnerabilities that could allow unauthorized access to other patients’ records. Gematik addressed these issues before the nationwide rollout. In February 2026, two incidents occurred: an eight-hour IT outage caused by a data center failure, and a data breach at AOK Bayern, where 6,400 records were mistakenly locked. No data was lost in either case, but these events highlight that the infrastructure is still maturing.