Why Central Emergency Departments Are Structurally Overloaded – and How Digital Patient Steering Stabilises Hospitals

1. The Tension Between Demand, Standby Requirements and Financial Crisis

Central emergency departments are an indispensable part of acute and emergency care, but also an area of high structural complexity and considerable standby costs. In Germany, the utilisation of emergency departments has reached a high level and has recently risen again. For 2024, the Federal Statistical Office reports approximately 13.0 million outpatient emergencies in hospital emergency departments – the highest level since records began in 2018.

In parallel with high demand, the financial situation of hospitals in Germany has deteriorated significantly. The Hospital Rating Report 2025 describes a further deterioration for 2023 and reports that 56% of hospitals could report annual losses. Creditreform documents 88 insolvencies of hospitals and clinics in Germany between 2020 and 2024.

The central thesis of this paper is therefore: the economic stabilisation and relief of the emergency department requires active patient steering. This only becomes effective through digitally supported initial assessment with binding telemedicine follow-up care and outpatient partner pathways.

2. Economic Mechanics of Underfunding in Emergency Departments

2.1 Standby Costs and Regulatory Requirements

Central emergency departments are not variable service areas, but structurally highly resource-intensive units. The introduction of tiered emergency care defined binding minimum requirements for personnel, equipment and organisational structures. These regulatory requirements lead to a high fixed cost share that arises regardless of individual case severity.

2.2 Revenue Structure of Outpatient Emergency Treatments

Outpatient emergency treatments in hospitals are predominantly reimbursed through EBM mechanisms. Health economic analyses show that this reimbursement is often not cost-covering. The emergency department thus becomes a high-cost environment with limited revenue potential for outpatient cases.

2.3 Misallocation as a Structural Economic Problem

Approximately 61% of emergency department cases remain outpatient, while the proportion of potentially GP-treatable self-referrals is estimated at 30–50%. Economically, this creates a classic allocation error, as resources with high fixed costs are used for services that could be provided in a lower cost structure.

2.4 Strategic Imperative: Transformation Instead of Optimisation

Previous measures to relieve emergency departments focused on internal process optimisation. However, these address symptoms, not the cause. The central cause lies in the inadequate steering of patients to the appropriate level of care. Hospitals must fundamentally rethink the central emergency department.

3. Digital Patient Steering as Structural Transformation

3.1 From Information to Steering

Previous approaches only indirectly address what has been empirically identified as the main driver of low-urgency ED visits: uncertainty, poor accessibility of primary care, and the perception of the emergency department as a "safe place". What is missing is an active, patient-centred steering architecture that enables immediate follow-up care rather than merely issuing recommendations.

3.2 Artificial Intelligence as a Steering Element

The introduction of the Digital Health Navigator (DGL) at the University Hospital Halle (Saale) represents a first operational step. The DGL is a certified neural system for structured, adaptive medical history and initial assessment. Unlike freely learning AI systems, it is based on a controlled, study-based knowledge model.

3.2.1 Home-Assessment

The DGL is available browser-based and anonymously. Users are guided step-by-step through an adaptive medical history until a reliable picture of urgency, appropriate care level and possible causes is available. The primary goal is a targeted routing recommendation to the right level of care.

3.2.2 Pre-Assessment in the ED Waiting Area

In the waiting area, low-urgency cases complete a personalised digital assessment. The data is directly linked to the hospital information system. This structured pre-assessment enables calmer data collection, systematic querying and the avoidance of redundant initial consultations.

3.3 Systemic Impact: Steering Instead of Symptom Control

The actual structural impact unfolds through consistent further development: in the pre-clinical scenario, digital initial assessment is directly linked to a telemedicine consultation. Within the ED, low-complexity cases can be specifically redirected to affiliated outpatient structures.

3.4 Holistic Integration as Problem Solver

The true innovation lies not in the use of a digital history system alone, but in the structural linking of previously isolated elements: telemedicine follow-up as billable primary care, outpatient centre integration as a cost-efficient care level, AI-supported appointment management, and scalability through universal connectivity to external partners.

In this structural totality, there is currently no widely established comparable model in the German healthcare system.

4. Integrated Steering Architecture as Problem Solver

4.1 Proactive Instead of Reactive

The traditional logic of the emergency department is reactive: every person who appears is treated, regardless of whether the chosen level of care is optimal. Under current conditions, this logic is no longer sustainable. The Digital Health Navigator unfolds its impact as part of an integrated steering architecture that connects pre-clinical initial assessment, immediate telemedicine follow-up care and targeted redirection to outpatient structures.

4.2 Economic Leverage Through Redirection and Resource Focus

The economic effect results from the reduction of structurally underfunded cases in the ED and the better focusing of highly qualified resources on genuinely urgent treatment needs.

4.3 Targeted Resource Management and Future Viability

The structured digital medical history generates aggregable data sets before actual care contact. These enable real-time demand analysis and predictive capacity management. Digital patient steering thus operates not only at the individual case level, but at the system level. The emergency department becomes a highly specialised care segment, embedded in an intelligently managed care network.

5. Strategic Classification and Future Perspective

The economic situation of German hospitals in 2026 no longer allows for isolated optimisation projects. Digital patient steering with telemedicine follow-up, outpatient integration and data-driven resource management offers a concrete transformation pathway.

For hospitals, this means: economic relief of high-standby structures, strategic preparation for integrated emergency centres, improved positioning in the competition for skilled professionals, and higher resilience to demand peaks.

Those who want to secure the future viability of emergency care must actively shape patient flows rather than optimising existing processes.