Madis Tiik CEO Estonian e-Health Foundation Baltic Congress in Laboratory Medicine 16 September 2010

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

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

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 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 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 (1.5 mln € – 2010) 5

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

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

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 Storage ( long time archive) Metadata/ universal viewer

Current Situation There are documents in the Estonian EHR Discharge letters (epicrises) Out-patient consultation notes Dispensed medication information DICOM images ( index) Image reports More than citizens have digital medical records in EHR, it is 30% of the population

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

ePrescriptions Prescription centre was launched 1st of January 2010 JanuaryFebruaryMarchAprilMayJuneJulyAugust Number of e- prescriptions issued % from prescriptions issued* 40%58%74%55% 58%55%62% Purchased prescriptions % from purchased prescriptions* 21%31%46%41%42%46%45%48% *estimation based on 2009 numbers prescriptions monthly ** recomendation not to use e-prescription to the doctors

eLab project Translation of LOINC terms Implementation LOINC and RELMA program's in all labs Mapping of Lab’s test’s with LOINC standard. Influence to the other projects: Enables data exchange between labs and healthcare providers Enables statistical analyzes and comparisons Test results are seen to all users of EHR Enables patient’s to see lab test More info for decision support Automatic exchange data with Infectious diseases register

Workflow of lab test’s Doctors IT system Sample logistic Lab EHR Referal (patient ID, test specifikation, index number) 3. Referal (test specifikation, index number) 5. Lab test result(index number) 6. Report, alerts, lab test results Referal centre 4. Sample + index number

Lab test standard --> 9.2 Vol % 10 Vol %

Life Cycle of Digitization of Medical Document Task Setup Ministry of Social Affairs, EeHF, Professional Society’s Content Related Standardization The Estonian eHealth Foundation (EeHF) Technical Standardization – CDA document Developer (Outsourcing) Development of Central System ServicesDevelopment of Health Care Service Providers’ Developer (Outsourcing)Information Systems Health Care Service Provider’s ICT partner Installation Standard to the Test Environment (EeHF) Testing and Acceptance Services Developer, EeHF, Health Care Service Provider’s ICT partner Ministerial degree naming the date for Health Care Providers when standard and new documentation is obligatory - Ministry of Social Affairs Standard published, installed to working environment, new service in portfolio of EeHF- EeHF

Patient’s Portal → Personal Health Record (PHR) 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 Future of EHR

EHR Portal Services for Citizen

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

Decision Support Core Engine EBMeDS Local Service Estonian NHIS HCI workspace EHR Document Service Global, National & Local Scripts Evidence Links Function Library Patient Data Forms & Calculators Response Messages Drug Information Best Practice Contraindications Interactions Conversion filters”Glue” component EHR Decision Support Web Server Application EBMeDS Evidence-Based Medicine electronic Decision Support HTTP Web Resources EBM Guidelines Cochrane Library Essential Evidence EBMeDS Home Page Script Editing Tools EBMeDS Database EBMeDS Master File Package EBMeDS Central Service Administrator Tools Testing Applications Testing Applications Table Editing Tools Compiling Tools JavaScript Interpreter Data Tables FTP Log Files Update Service

Application Maintenance Server, Storage & Network Management Database management Monitoring help desk Application Operations Hardware and Data Center Application Development Business Processes Partners eHealth Partners ITIL Maintenance of Estonian EHR System

Application Development Server, Storage & Network Management DataBase Management Monitoring, Help Desk Application Operations a 4b Hardware & Data Center Maintenance of the EHR Application Maintenance and Support Business Processes Doctors portal Patient Portal W-SS EHR reguest servicis Patient summary Medication history Incident Management Service Request Management Capacity Management Change and Release Management Problem Management Service Level Management Service Continuity ManagementOperations Demand Management Configuracion Management

Lessons learned 1 Clear governance and decision making Agreement of standards before the start of the implementation Preparation of proper legal environment including strict rules for patient delicate data handling Involvement of the main stakeholders Reuse already working IT solutions made by State ID card X–road

Lessons learned 2 Access rights Finding suitable compromise between different stakeholders – citizen, physician, state Controls before Access is provided to all licensed medical professionals only (attending physician concept) Institutions are responsible for their internal controls Controls after Monitoring based on risk analysis 24

Thank you for your attention! Questions?