The presentation provides an overview of the experience of implementing national systems and lessons learned.

1. “Black & White”
Igor.Bossenko@Kodality.com
01.12.2018

3. Igor Bossenko @ Healthcare
➤ Estonian Blood System “father”, architect -
1995/2005
➤ HIS ESTER3 “father”, architect - 1999/2005
➤ HIS eHL “father” & architect - 2005/2013
➤ HL7 V3 standard visioner & implementor in
Estonian NHS - 2006
➤ Labscala Quality Laboratory (Finland) - 2011
➤ Lithuanian NHS visioner & FHIR standard
implementor - 2014/2016
➤ FHIR community member and contributor - 2014/..
➤ OAE Abu Dhabi e-Prescription - 2017/2018
➤ HIS HEDA “father” & architect - 2018/..

4. Estonia
• Healthcare expenditure 6,3% vs 9% of
GDP as OECD average (2015 data)
• Life expectancy at birth in last 10
years: +4,8 years (now 77,2)
• 100% electronic billing in healthcare
• 99%+ use of digital prescription over paper
• Standards based medical data collection HL7 V3
• 99% coverage of central Health Information
Exchange
• Central data about each visit to doctor:
• diagnosis, procedures, cost, GIS data available
• Secure patient access to medical data using digital ID

5. 2000 – 2010 development of
Estonian NHS
2000 2002 2004 2008
Planning of health
data exchange
started
Project
preparation
(2003-2005)
2006
Funding decision by Ministry
of Economic Affairs
Electronic
Health Record
Digital
Prescription
Digital
Registration
Digital Images
eHealth
Foundation
established
eHealth
Projects
(2006-2008)
National HIS
18.12.2008
2010
ePrescription
01.01.2010
X-road first
services
Estonia entered
into European
Union

6. #1
Estonia is the first country which has
implemented a nationwide electronic health
record system and gives full access to its citizens.
This provides new opportunities to citizens,
healthcare providers and e-health developers
Тhe international council on medical & care compunetics
(http://recordaccess.icmcc.org/tag/portal/)
“Patient Opportunities in the Estonian Electronic Health Record System”

7. Estonian eHealth architecture
PHARMACIES
AND FAMILY
DOCTORS
X-Road, ID-card, State IS Service Register
HEALTHCAREBOARD
-Healthcareproviders
-Healthprofessionals
-Dispensingchemists
STATEAGENCYOFMEDICINES
-CodingCentre
-Handlersofmedicines
POPULATIONREGISTER
BUSINESSREGISTER
HOSPITALS
2009
FAMILYDOCTORS
2009
SCHOOLNURSES
2010september
ANONYMIZED
HEALTH DATA
FOR STATISTICS
2013NATION- WIDE
HEALTH
INFORMATION
SYSTEM
2008 december
PRESCRIPTION
CENTRE
2010january
DOCTOR
PORTAL
2013
X-ROAD
GATEWAY
SERVICE
2009

8. Standardisation
• Strategic choice of technological standard
• HL7 version 3
• CDA
• A template-based data model that describes a process or
object.
• Documents consist from the blocks created on the basis
of templates

13. Example of allergy block

15. Is everything so good (HCF)?
• Responsibilities were given to health care
facilities, but no funding was provided.
• Small developers & pharmacies were forced to
quit
• Political decisions were made by health facilities
in order to preserve the market

16. Is everything so good (tech)?
• A lot of standard extensions. As a result, no other
country will understand the messages sent.
• Very massive XML. High requirements for disks,
processors, memory.
• The reluctance of developers to work with integrations
(from the complexity of XSD, XML, XSLT)
• The number of templates created is huge.

17. Number of documentation on templates
2011
2018

18. Estonian Patient Portal

19. Lithuania
• Healthcare expenditure 6,5% vs 9% of
GDP as OECD average (2015 data)
• Life expectancy at birth in last 10
years: +4 years
• 100% electronic invoices
• Standardized HL7 FHIR medical data
sharing, used by 80% of medical facilities
• Central data about each visit to doctor:
• diagnosis, procedures, cost, GIS data
available
• Secure patient access to medical data using
digital ID

20. Lithuanian medical ecosystem
Lithuanian
eHealth
Information
ecosystem
NHS
Integration
layer
eHealth portal
Reports &
statistics
Medical
Image Bank
ePrescription 176 Healthcare
providers
National register
Authentification
Health
insurance fund
Social insurance
fund
Disability assessment
organization
Internet patient
registration

21. The devil is in the details
• Registrų centras (center of registers)
• Tender organizer
• Owns most of the country’s registers.
• Missing architect and standardization team
• Document-based thinking
• Before us there were 2 unsuccessful attempts to implement the central system.
• Term 1.5 years (equivalent in Estonia for 5+ years)
• The tender took place in a short time.

22. Tender changes
Dec
2013
Jan
2014
Feb
2014
Database Portal
Mar
2014
SignatureStandard

23. Architecture
• Oracle DB
• Jboss Fuse
(OSGI,
Karaf)
• Apache CXF
• OAuth
• Angular 1.x

24. OSGI + FHIR
• Modular system
• N parallel versions
• API versioning by design
• Basic modules for permissions,
resource storing, and other
functionality with well-defined
interfaces
• Specific modules for a specific
task: documents, notes,
prescriptions, images, etc.

25. Database solution.
One table per resource or data type

26. One table per resource or data
type
• Pros
• Classic RDBS Solution
• Easy to understand for non-
FHIR people
• Suitable for all BI tools.
• Good response time (*)
• Ability to optimize queries
• Works on all databases
• Cons
• Db structure is too ugly
• Too static, does not support
new resources or profiles.
• Every extension needs to be
programmed.
• All searches are hardcoded,
it’s not possible to add
parameters dynamically.

28. Doctor portal

29. #1
Lithuania is the first country in the world to
implement the FHIR standard at the national level
and provide hospitals and patients with access to
medical records, documents, prescriptions and
digital images.

30. Emirate of Abu Dhabi (UAE)
• UAE consists of seven independent
emirates
• Thanks to the income from oil exports to
Abu Dhabi, one of the highest per capita
incomes in the world.
• Abu Dhabi provides about 70% of the
country's GDP.
• Population - 2 120 700 people (for 2011)
• Mainly American Cerner & Epic
software work in hospitals.
• Drug usage prohibited

31. Control Narcotic Medication
(CNM)
• Participants:
• Hospitals
• Pharmacies
• Police
• Target - keep records of prescribed (in hospitals) and
dispensed (in pharmacies) narcotic drugs and allow
verification of the presence of narcotic medications among
citizens (by the police)

32. е-Prescription (resources)

33. Blaze FHIR server

34. projectcrucible.org
• Passed ~1700 tests
• Problems with external
libraries …

35. DB = PG + NonSQL + partitioning +
JSON/XML index + custom indexes

36. SMART on FHIR Scopes and
Launch Context
• Rights for the organization only writing prescriptions:
• user/Patient.*; user/MedicationRequest.*; user/Organization.read; user/
Practitioner.read; user/Medication.read; user/MedicationDispense.read;
• Rights for the organization only issuing drugs:
• user/Patient.*; user/MedicationRequest.read; user/Organization.read; user/
Practitioner.read; user/Medication.read; user/Provenance.*; user/
MedicationDispense.*;
• Information stored in the Jasig CAS scope attribute

37. REaaS integration (supporting
external rule engine)

38. Adaptation of business logic
instead of standard extension
• Prescription locking (to prevent dispense of the medicine in two places at
the same time)
• (analyst) add status to the prescription
• (solution) the pharmacy hangs up the lock / Provenance, which
becomes obsolete within 20 minutes or after dispensing the medicine
• Tracking the number of drugs issued
• (analyst) pharmacy changes the data on the prescription
• (solution) MedicationDispense changes the number of drugs issued on
MedicatioRequest automatically (pharmacy can’t change prescription)

39. Ethereum based blockchain

40. #1
• Abu Dhabi CNM - the first implementation of
FHIR in the Gulf
• The first project with blockchain support in the
Emirate of Abu Dhabi

41. Conclusion

42. Common characteristics of success
• Relatively small countries (up to 3 million)
• Presence of national ID
• Presence of authentication system
• Presence of governmental IT infrastructure available for all (a la xRoad)
• Presence of legislative base
• Requirement for clients (medical institutions) to implement the system by deadline
• Usage of worldwide standards
• Helps avoid controversy when implementing a system
• The presence of a non-profit organization responsible for the development of
standards (*)

43. Extensions
• ~80% templates of HL7 V3 in Estonia have
extensions
• ~50% resources of HL7 FHIR v0.5 in Lithuania
have extensions
• 0% resources of HL7 FHIR v3.0.1 in UAEhave
extensions

44. What to consider
• Try to use the standards as is (as they were designed). If you deal exclusively
with extensions of the standard, then you are not using them correctly.
• Healthcare process is not a piece of paper, it is a continuous process of
treatment. Do not create exchange system for documents, such as “patient
record”, “case report”, etc. Exchange medical resources and create documents
based on these resources.
• Digital signature. Doctors do not want to sign each document separately - it
takes too much time.
• Integrate medical facilities through a single central system
• End users (hospitals, doctors and patients) should be interested in using central
system. Find a candy/motivation for everyone.

45. And finally
• Provide clear documentation for doctors.
• Give doctors and patients time to learn. Invest in training, then the system will use!
• Involve doctors in the design process. It is important to know that what you are doing is not
detached from reality, and hospitals will be able to adapt their systems to your requirements.
• Data quality is very important. Not enough time or not high-quality data can undermine the
credibility of the system
• Avoid repetitive research and analysis (document based approach)
• Continuous development: Get users first.
• Plan funding for both - the central system and hospitals
• Time is the most valuable resource of the project. A project can very easily get out of schedule,
since usually no one imagines its real complexity in the beginning.
• Standard solutions reduce the number of unpredictable problems - learn from others!

46. Igor.Bossenko@Kodality.com
Thank you!