Estonian Health Information System

Raul MillEstonian eHealth Foundation

Estonia - 45 000 km21.29 mlj. inhabitants

GDP:Agriculture 2,7%Industry 26,3%Service 74,5%

Estonia

306.02.2013

406.02.2013

HEALTHCARE IN ESTONIA

35 hospitals491 family doctors (juridical persons)

Healthcare expenditures- 5.9% from GDP 2011- 6.3% from GDP 2012

5

E-STATE ARCHITECTURE

706.02.2013

SECURITY & AUTHENTICATION

8

PHARMACIES AND FAMILY DOCTORS2009

X-Road, ID-card, State IS Service Register

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NATION- WIDEHEALTH INFORMATION EXCHANGE PLATFORM2008 december

PRESCRIPTION CENTRE2010 january

PATIENT PORTAL2009

X-ROAD GATEWAY SERVICE2009

Architecture

2000 2002 2004 2006 2008

HIE platform historyPlanning initiated

Project preparation (2003-2005)

Funding decision by Ministry of Economic Affairs

Electronic Health Record

Digital Prescription

Digital RegistrationDigital Images

eHealth Foundation established (2005)

eHealth Projects (2006-2008)

National HIE

Standards management

ITmanagement

Ministry of Social Affars

East Tallinn Central Hospital

Tartu University Clinic

Society of Family Doctors

North Estonian Regional Hospital

Management board

Estonian e-Health Foundation Board

ENHIS Operation

EstonianHospital Assosiation

Union of Estonian Medical Emergency

Organization

Services management

Communication management

Medical Advisory Board

1106.02.2013

35 hospitals491 family doctors

8 main softwares (20 totally)

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The main principles of security of Estonian eHealth system – Opt Out

1. A secure authentication of all users with ID-card or Mobile ID2. Digital signing or stamping of all medical documents3. A maximum accountability (transparency): all actions will leave an

unchangeable (and unremovable) secure trail4. Encrypted database that allows to remove the confidentiality risk

from the technical administrators5. Monitoring of all actions together with the corresponding counter-

measures (both organizational and technical)

13

STANDARDS

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Standards

• HL7 and DICOM (Picture Archive)• International classification: ICD-10, LOINC,

NCSP, ATC• Estonian eHealth’s OID registry• Local eHealth classificators

– Published in publishing centre– Classificators are regulated by government act

https://www.riigiteataja.ee/akt/12910889

15

Standardization process

Create data set

Formalize and merge

Approve and publish

Data set document Classificators

Examples

Specialty assotiations

OID-s

XML schemas

Description documents

UML model

Healthcare providers

EeHF standardization

specialists

Social ministry

Stylesheets

UML+HL7 experts

Fixed version of artifacts in

publishing centre

Terminology experts

HIS developers

Health Insurance

Fund

Changes in NHIS documents

regulatory act

Central System– Database and related services

Data Exchange level different e-services

Institutional level– users cooperation model

• Healthcare processes• User needs• Training programs

• Partnership• Communication

The structure of Estonian Health Information System

• Set of data• Data Standards• Search criterias• Legal Framework• Software• Hardware

• User Software• User interface• Data input• Data Visualisation• Search information

• Data transmission standards (HL7)

EHR services for patient

Services for Social

Insurance Fund

Services for dentaal care

Services for blood center

Services for registers

Services for nurse

Services for homecare

Health information services for

patient

E-learning services for

medical staffAnalytics

services for participants in

treatment process

Data and statistics services

A medical certificate services

Digital laboratory

services

eAmbulance services

Cross Border Data Exchange

services

Digital archiving services

eConsultation services

Digital registration

services

EHR services for physician

Main services of the e-health in Estonia

Infrastructure services External servicesCentral System– Database

and related services

Data Exchange level different e-services

Institutional level– users cooperation model

Supporting services

Subservices

Patients Public Register

BusinessRegister

Dental care

Blood center

Military Forces

Homecare

Genome Center

Nursing careMedical statistics

Medical Registers

Emergency Medical

Departments

eAmbulance

Social Insurance

Board

Health Insurance Fondation

Family Doctors

Health Care Board

HospitalsMain e-health participants on the x-road

Infrastructure services

External servicesCentral System– Database

and related services

Data Exchange level different e-services

Institutional level– users cooperation model

Supporting services

Subservices

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Documents total – 12.8 mio

1.2 mio persons medical data (growth 20% during 2012 and 15% during 2013)

PATIENT PORTAL (UPGRADE)

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Acceptance

• ePrescription covers 94% of issued prescriptions.• Over 90% of Hospital discharge letters – digital• Over 97% of stationary case summaries have sent to the central DB• Ambulatory case summaries sending

– No certain rules for sending ambulatory case summaries!• 1.2 mio person have documents in central system (92% of population)• 92% of family doctors are sending documents on a regular base• All bigger hospitals use central system on a regular base• The central system has over 8700 medical users

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2009 2011 2015 2017 20191999 2003 2005 20072001

You are here

Family doctors who are sending documents 52% 92%Queries in a month 60 000 260 000

Visits of the patient portal in a month 40 000 160 000

Rate of sent stationary treatment cases 97%

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ePrescription (94%)

jaan.10

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may.12

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

ISSUED SOLD

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Retrieval of Medical Documents by Healthcare Professionals

Mar

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June July

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Nov

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Janu

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Janu

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2009 2010 2011 2012 2013

0

20,000

40,000

60,000

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100,000

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140,000

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180,000

200,000

220,000

240,000

260,000

280,000

24

Patient portal Number of queries 12.2008 – 10.2013

DETS 2

008

VEEBR 2009

APR 2

009

JUUNI 2

009

OKT 2

009

DETS 2

009

VEEBR 2010

APR 2

010

JUUNI 2

010

AUG 2

010

OKT 2

010

DETS 2

010

VEEBR 2011

APR 2

011

JUUNI 2

011

AUG 2

011

OKT 2

011

DETS 2

011

VEEBR 2012

APR 2

012

JUUNI 2

012

AUG 2

012

OKT 2

012

DETS 2

012

VEEBR 2013

APR 2

013

JUUNI 2

013

AUG 2

013

OKT 2013

DETS 2013

VEEBR 2014

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

eHealth availability and use Indicator 2012: by country

26

E-health approximate expenditures untill 2012Country ExpendituresExpenditures per

capitaEstonia 12 mil EUR

9,1 Ireland 56 mil EUR

12,2Portugal 69 mil EUR

6,5

Norway 105 mil EUR 20,8Scotland 117 mil EUR

22,5Denmark 183 mil EUR

32,7Finland 203 mil EUR

37,4Sweden 347 mil EUR

36,2Netherland 430 mil EUR

25,7Spain 713 mil EUR

15,5

Germany 1 352 mil EUR 16,8UK 1 980 mil EUR

31,3Australia 4 976 mil EUR225,1US 30 712 mil EUR

97,2

2706.02.2013

LEARNING POINTS

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Healthcare is a reactive, rather than proactive industry.

Solve one specific problem in healthcare, not ten of them.

In healthcare you need to have a business model from the start.

Healthcare is very interdependent: you have the doctor, the pharmacy, the patient, the insurance provider, and a dozen other stakeholders that

any one service has to coordinate with.

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• Comperhensive planning – processes and standards, legislation. • Usability – fast and simple solutions• Implementation – central training programs• Service update – continuous feedback• Balance between security and usability

– PIN for every document …– PIN or ID-card?

30

January

February

March AprilMay

JuneJuly

August

September

October

November

December

January

February

March AprilMay

JuneJuly

August

September

October

November

December

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

Medical document sent to Health Information System by General Practitioners 2012-2013

Impact of the digital stamp since 2013Documents sent by family doctors in a month have increased up to

4x!

vocations

vocations

3106.02.2013

FUTURE OUTLOOK

Data and services

integrationApps for medical

specialties

UI standards

Single sign on

Hardware independent

Inter-operability

Graphical solutions

Collecting information

Location independent

Voice recognition

and text input

assistant

33

Thank you!