The Status of National e-Health Initiatives in Estonia Madis Tiik 18.06.2010 CEO Estonian e-Health Foundation

Facts about Estonia Population 1.32 million Area 45 000 km2 Compulsory health insurance paid by employer Health insurance tax 13% Health care costs make up 5% of GDP Income tax 21% (flat tax) Healthcare providers are private, municipal or governmental. Family doctors (private companies) Hospitals (shared companies or foundations)

e-Estonia Wide range of e-services High bandwith connectivity e- election (EU Parliament election june 2009 – 6,5% electronically) e- tax board (2008 – 90,6% electronically) e- school e- commercial registri, etc High bandwith connectivity Internet 75% of population use regulary internet (2009) 67% households have PC and 91% of them are connected to the

Information Society By 2013 All public services are digitaly available Public infrastruture is service oriented (x road) Digital authorisation of users, based on the ID card, is the best available in the world Data is stored were it is collected and exchange of the data is available thous who need it

DATABASES / INFORMATION SYSTEMS BANKS SEBbank Swedbank Creditbank Sampo Bank Nordea Bank Population register Health Insurance Register National Pension Insurance Register Vehicle Register Estonian Energy IS Tallinn Water IS Security Server Security Server Security Server Security Server Security Server Security Server Security Server Internet - X-tee Security Server ID – card Security Server :: … :: Central server I Monitoring National Databases register http://www.riik.ee/arr/ E-institution – Institution view :: E-county – county view :: :: E-riik – State Portal :: Institutional view of the state Thematic view of the state www.riik.ee www.eesti.ee Central server II Helpdesk KIT Citizen view EIT Enterpriser view AIT Public servant view X-road certification centre Tools centrally developed by the State X-road Center Certification Center

X-road Aggregates 360 different databases 2000 e-services 500 different organizations have integrated their systems into X-road Services of X-road were used 420 000 000 times a year (2009) more information http://www.ria.ee/27525

Access rights for EHR All healthcare providers must send data to EHR Regulated by the law Access only to licensed medical professionals The attending doctor concept ID card for authentication and digital signature Patient has the right to close his/her own data collected to the central database (opt out) Citizen can access their own data Citizen can declare their intentions and preferences Citizen can monitor visits to their EHR

EHR Lifestyle Self-help Tele-advice Appointment Notification Prescription Campaigns Public Services Policy- making Analysis Diagnostics Treatment Guidlines Follow-up EHR Workflow

Founders of the Estonian eHealth Foundation Family doctors Hospitals Founders of the Estonian eHealth Foundation End users Strategy and Architecture Development Marketing and Channel Management Ministry of Social Affars East Tallinn Central Hospital Tartu University Clinic Society of Family Doctors North Estonian Regional Hospital Management Board Estonian eHealth Foundation Board EHR Operation Estonian Hospital Association Union of Estonian Medical Emergency Nursing Care Patient Portal Health Authorities Governance

Our tasks Financed from the State budget (1.2 mln € – 2008) Management of E-Health projects Standardisation and development of medical digital documents Maintenance of the Estonian EHR system International cooperation and scientific cooperation with universities Development of new services for citizens and doctors Financed from the State budget (1.2 mln € – 2008)

HEALTH INFORMATION SYSTEM ( EHR) HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists Hospitals 2009 Family doctors Emergency Medical Service 2011 School nurses 2010 september SS Pharmacis 2010 january STATE AGENCY OF MEDICINES - Coding Centre - Handlers of medicines Citizen Registry Company Registry SS SS SS SS HEALTH INFORMATION SYSTEM ( EHR) 17.12.2008 SS X-ROAD Patient portal SS SS Monitoring portal Healthcare Provider HEALTH INSURANCE FUND Prescription Centre 2010 january Goverment’s e-service framework www.eesti.ee KIT Citizen view EIT Enterprice view AIT Official’s view W-SS Doctor’s and pharmacies software solutions Estonian national eHealth infrastructure

EHR Central Functions Health Portal Devices Information Systems Standards and Services Processes and Integration WSDL XSD Public IT Infrastructure Concent Document archive Health record Statistics Decision Support Reports Health status Ambulance Demo-graphics Booking EHR Central Functions Metadata/ universal viewer Storage ( long time archive)

Current Situation 17.06.2010 There are 1 557 704 documents in the Estonian EHR Discharge letters (epicrises) 186 460   Out-patient consultation notes 244 609   Dispensed medication information 743 944 DICOM images ( index) 213 397 Image reports 164 069 More than 370 000 citizens have digital medical records in EHR , it is 25% of the population

Availability of Discharge Letters Year 2009 North Estonian Regional Hospital Tartu University Clinic East Tallinn Central Hospital 27661 31914 24038 82% 74% 84% These 3 hospitals cover more than 60% of in-patient cases in Estonia

ePrescriptions Prescription centre was launched 1st of January 2010 January February March April** May Number of e-prescriptions issued 278 957 407 609 520 000 387 000 381 836 % from prescriptions issued* 40% 58% 74% 55% Purchased prescriptions 150 009 221 800 322 000 288 000 292 207 % from purchased prescriptions* 21% 31% 46% 41% 42% *estimation based on 2009 numbers - 700 000 prescriptions monthly ** 13.04 recomendation not to use e-prescription to the doctors

Patient’s Portal → Personal Health Record (PHR) 2010-2011 PHR – one view for citizens Illness data from healthcare system (Patient’s Portal) Self-monitoring data Wellness data from third parties Data from social system Patient forums Screening remainders Decision support Self-care Virtual health check

EHR Portal Services for Citizen Interactive Services Viewing Prescriptions Viewing Health Record E-consultation Immunization Passport Virtual Health Check Certificates, Recommendations Citizen Health Record Collecting Personal Health Information Self-help Personal Data Management Informational Services Reminders Invitation for Screening Booking Service Supporting Services Rights Management Authorizations Expressions of Will Access Rights Log Archive EHR Portal Services for Citizen

Decision Support TIS Knowledge Digitalization Decision Support Service Suggestions and Reminders Decision Support Service Decision Scripts Health Records Digital Library Health Records Service

Applications X-Road Message centre Message broker Message agents End user services, hospital IT services Patient: Oracle Portal Hospital IS X-Road Sending messages between institutions X-Road infrastructure Message centre Message validation, authorisation, logging, addressing webMethods Integration Server, custom Java services Message broker Forwarding messages to agents webMethods Broker Message agents Document processing webMethods Integration Server Data services Database operations, database logging, queries webMethods Integration Server, Oracle DBMS

EHR integration through X-Road HL7 document HL7 interaction Hospital IS EHR X-Road message

Document processing Message HPI Lab notice Swineflu notice Üldandmed Mari-Liis 47595064059 Männi 1-2 Tallinn Diagnoos punetised Allergia õietolm Health record Health record agent Event: Medication, Diagnosis, Procedure Swineflu notice Üldandmed Mari-Liis 47595064059 Männi 1-2 Tallinn Diagnoos punetised Allergia õietolm Infection notice Üldandmed Mari-Liis 47595064059 Männi 1-2 Tallinn Diagnoos punetised Allergia õietolm Demographics Demographics agent Address: Männi 1-2, Tallinn Discharge letter Demographics Mari-Liis 47595064059 Männi 1-2 Tallinn Diagnosis chickenbox Allergy pollen Statistics query Outbreak report HPI Data integration Demographics, health status HPI services Infection decease agent Diagnosis: chickenbox Timecritical reports Timecritical report agent Allergy: pollen

Maintenance of Estonian EHR System Application Maintenance Server, Storage & Network Management Database management Monitoring help desk Application Operations Hardware and Data Center Application Development Business Processes Partners eHealth ITIL Service Continual Process Improvement Service Design Service Transition Service Operation Service Strategy

“Have an eExperience in Tallinn” eHealth Conference in Tallinn 13-15 October 2010 www.ehealthtallinn2010.org The Estonian eHealth Concept Translating the Benefits & Cost of eHealth - Assessment of Economic Impact of the Estonian Health Information System (DIGIMPACT) Opt-in or Opt-out? User Rights, eHealth Related Legal and Privacy Issues in Estonia Open Discussion: How Was the Estonian National Health Information System Implemented? Overview of process, problems we have encountered, different parties’ viewpoints on implementation (e.g. physicians and patient representatives).

Thank you for your attention. Questions. Madis. Tiik@etervis. ee www Thank you for your attention! Questions? Madis.Tiik@etervis.ee www.e-tervis.ee http://eng.e-tervis.ee/