Raul Mill from Estonia describes the eHealth systems in use in his country.

1. Estonian eHealth System
Raul Mill
Estonian eHealth Foundation

2. Hello!

3. GDP:
Agriculture 3.9%
Industry 29,7%
Services 66,4%
Estonia
Area - 45 000 km2
1.33 mlj. inhabitants

4. Healthcare expenditures in Estonia
- 6.9% from GDP 2013 – 1.12 bln eur
- 5.9% from GDP 2012 – 1.03 bln eur
- 5.9% from GDP 2011 – 0.94 bln eur
- 6.3% from GDP 2010 – 0.91 bln eur

5. E-STATE ARCHITECTURE

7. 8 main softwares (totally 20)
752 associated juridical persons
21 main hospitals
73 stationary healthcare institutions (hospitals)
479 family doctors (juridical persons)

8. 2000 2002 2004 2006 2008
HIE platform history
Planning
initiated
Project
preparation
(2003-2005)
Funding decision by
Ministry
of Economic Affairs
Electronic
Health
Record
Digital
Prescription
Digital
Registration
Digital
Images
eHealth
Foundation
established
(2005)
eHealth
Projects
(2006-2008)
National
HIE

9. Standards
management
IT
management
Ministry
of Social
Affairs
East Tallinn
Central
Hospital
Tartu
University
Clinic
Society
of Family
Doctors
North Estonian
Regional
Hospital
Management board
Estonian e-Health
Foundation Board
ENHIS Operation
Estonian
Hospital
Assosiation
Union of Estonian
Medical
Emergency
Organization
Services
management
Communication
management
Medical
Advisory
Board

10. PHARMACIES AND
FAMILY DOCTORS
2009
X-Road, ID-card, State IS Service Register
HEALTHCAREBOARD
-Healthcareproviders
-Healthprofessionals
-Dispensingchemists
STATEAGENCYOFMEDICINES
-CodingCentre
-Handlersofmedicines
POPULATIONREGISTER
PHARMACIS
2010january
BUSINESSREGISTER
HOSPITALS
2009
FAMILYDOCTORS
2009
SCHOOLNURSES
2010september
EMERGENCYMEDICALSERVICE
2011
NATION- WIDE
HEALTH
INFORMATION
EXCHANGE PLATFORM
2008 december
PRESCRIPTION
CENTRE
2010 january
PATIENT PORTAL
2009
X-ROAD GATEWAY
SERVICE
2009
E-health architecture

11. The main security principles of
Estonian eHealth system – Opt Out
1. A secure authentication of all users with ID-card or Mobile ID
2. Digital signing or stamping of all medical documents
3. A maximum accountability (transparency): all actions will leave an
unchangeable (and unremovable) secure trail
4. Encrypted database that allows to remove the confidentiality risk
5. Monitoring of all actions together with the corresponding counter-
measures (both organizational and technical)

12. 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
• Searching information
• Data transmission standards (HL7)

13. EHR services
for patient
Services for
Social
Insurance
Fund
Services for
dental care
2015
Services for
blood center
2016
Services for
registers
2015
Services for
nurse
2016
M-and tele-
health services
Health
information
services for
patient
E-learning
services for
medical staff
Analytics
services
Data and
statistics
services
A medical
certificate
services
Digital
laboratory
services
2015
eAmbulance
services
2014
Cross Border
Data Exchange
services
2013 (EPSOS)
Digital
archiving
(x-ray images)
eConsultation
services
Digital
registration
2016
EHR services
for physician
Main services of the
eHealth in Estonia
Subservices
- Completed
- Development
- Planning
Infrastructure
services
External
services
Supporting
services
Connecting
Health

14. Acceptance
• All bigger hospitals use central system on a regular base
• The central system has over 10 300 medical users
• ePrescription covers 98% of issued prescriptions
• 98% of family doctors are sending documents to the central system
• Over 97% of stationary case summaries have sent to the central DB
• Ambulatory case summaries sending
– No certain rules for sending ambulatory case summaries!
• 1.35 mio persons have documents in central system (98% of the population)
• 0.74 mio persons information in the central DB have used by medical professionals

15. 0
50000
100000
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350000
400000
450000
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Mai
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Mai
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Okt
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Mai
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Sep
2008 2009 2010 2011 2012 2013 2014
Retrieval of medical documents by healthcare professionals 2009 - 2014
0
50000
100000
150000
200000
250000
Queries from patient portal

16. 0
20000
40000
60000
80000
100000
120000
140000
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEPT
OKT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEPT
OKT
NOV
DEC
JAN
FEBR
MAR
APR
MAY
JUN
JUL
2012 2013 2014
Sent documents by family doctors 2012 – 2014 – before and after realizing digital stamp

17. PATIENT PORTAL (UPGRADE) – 1.3 mio persons medical data

18. Standards

19. 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

20. 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

21. eHealth availability and use Indicator 2012: by country

22. LEARNING
POINTS

23. 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.

24. EHR systems: more like plain than mobile phone …

25. FUTURE OUTLOOK

26. Data and
services
integration
Apps for
medical
specialties
UI standards
Single sign
on
Hardware
independent
Inter-
operability
Graphical
solutions
Collecting
information
Location
independent

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

28. Thank you!