1. Estonian Health Information System Raul Mill Estonian eHealth Foundation

2. Estonia - 45 000 km2 1.29 mlj. inhabitants GDP: Agriculture2,7% Industry26,3% Service74,5% Estonia

3. 06.02.20133

4. 4 HEALTHCARE IN ESTONIA 35 hospitals 491 family doctors (juridical persons) Healthcare expenditures - 5.9% from GDP 2011 - 6.3% from GDP 2012

5. 5 E-STATE ARCHITECTURE

7. 06.02.20137 SECURITY & AUTHENTICATION

8. 8 PHARMACIES AND FAMILY DOCTORS 2009 X-Road, ID-card, State IS Service Register HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists STATE AGENCY OF MEDICINES - Coding Centre - Handlers of medicines STATE AGENCY OF MEDICINES - Coding Centre - Handlers of medicines POPULATION REGISTER PHARMACIS 2010 january PHARMACIS 2010 january BUSINESS REGISTER HOSPITALS 2009 HOSPITALS 2009 FAMILY DOCTORS 2009 FAMILY DOCTORS 2009 SCHOOL NURSES 2010 september SCHOOL NURSES 2010 september EMERGENCY MEDICAL SERVICE 2011 EMERGENCY MEDICAL SERVICE 2011 NATION- WIDE HEALTH INFORMATION EXCHANGE PLATFORM 2008 december PRESCRIPTION CENTRE 2010 january PRESCRIPTION CENTRE 2010 january PATIENT PORTAL 2009 X-ROAD GATEWAY SERVICE 2009 Architecture

9. 20002002200420062008 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

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

11. 06.02.201311 35 hospitals 491 family doctors 8 main softwares (20 totally)

12. 12 The main principles of security 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 from the technical administrators 5.Monitoring of all actions together with the corresponding counter- measures (both organizational and technical)

13. 13 STANDARDS

14. 14 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 https://www.riigiteataja.ee/akt/12910889

15. 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

16. 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)

17. 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 staff Analytics 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 services Infrastructure services External services Central System– Database and related services Data Exchange level different e-services Institutional level– users cooperation model Supporting services Subservices

18. Patients Public Register Business Register Dental careBlood center Military Forces Homecare Genome Center Nursing care Medical statistics Medical Registers Emergency Medical Departments eAmbulance Social Insurance Board Health Insurance Fondation Family Doctors Health Care Board Hospitals Main e-health participants on the x-road Infrastructure services External services Infrastructure services External services Central System– Database and related services Data Exchange level different e-services Institutional level– users cooperation model Supporting services Subservices

19. 19 Documents total – 12.8 mio 1.2 mio persons medical data (growth 20% during 2012 and 15% during 2013) PATIENT PORTAL (UPGRADE)

20. 20 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

21. 21 2009 2011 20152017 2019 1999 20032005 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%97%

22. 22 ePrescription (94%)

23. 23 Retrieval of Medical Documents by Healthcare Professionals

24. 24 Patient portal Number of queries 12.2008 – 10.2013

25. eHealth availability and use Indicator 2012: by country

26. 26 E-health approximate expenditures untill 2012 CountryExpendituresExpenditures per capita Estonia12 mil EUR9,1 Ireland 56 milEUR12,2 Portugal 69 mil EUR6,5 Norway 105 mil EUR 20,8 Scotland 117 mil EUR22,5 Denmark 183 mil EUR32,7 Finland 203 mil EUR37,4 Sweden 347 mil EUR36,2 Netherland 430 mil EUR25,7 Spain 713 mil EUR15,5 Germany 1 352 mil EUR16,8 UK 1 980 mil EUR 31,3 Australia 4 976 mil EUR225,1 US 30 712 mil EUR97,2

27. 06.02.201327 LEARNING POINTS

28. 28 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.

29. 29 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. 30 Impact of the digital stamp since 2013 Documents sent by family doctors in a month have increased up to 4x! vocations

31. 06.02.201331 FUTURE OUTLOOK

32. Data and services integration Apps 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. 33 Thank you!