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

3. 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)

4. 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

5. 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

6. 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
E-institution – Institution view
:: E-county – county view ::
:: E-riik – State Portal ::
Institutional view of the state Thematic view of the state
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

7. 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 times a year (2009)
more information

8. 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

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

10. 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

11. 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)

12. 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) SS
X-ROAD
Patient portal SS SS
Monitoring portal
Healthcare
Provider
HEALTH INSURANCE
FUND
Prescription Centre
2010 january
Goverment’s e-service framework
KIT
Citizen view
EIT
Enterprice view
AIT
Official’s view
W-SS
Doctor’s and
pharmacies
software solutions
Estonian national eHealth infrastructure

13. 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)

14. 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 25% of the population

15. 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

16. ePrescriptions
Prescription centre was launched 1st of January 2010
January
February
March
April**
May
Number of e-prescriptions issued
278 957
407 609
% from prescriptions issued*
40%
58%
74%
55%
Purchased
prescriptions
% from purchased prescriptions*
21%
31%
46%
41%
42%
*estimation based on 2009 numbers prescriptions monthly
** recomendation not to use e-prescription to the doctors

17. 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

18. 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

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

20. 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

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

22. Document processing Message HPI Lab notice Swineflu notice
Üldandmed
Mari-Liis
Männi 1-2
Tallinn
Diagnoos
punetised
Allergia
õietolm
Health record
Health record agent Event: Medication, Diagnosis, Procedure
Swineflu notice
Üldandmed
Mari-Liis
Männi 1-2
Tallinn
Diagnoos
punetised
Allergia
õietolm
Infection notice
Üldandmed
Mari-Liis
Männi 1-2
Tallinn
Diagnoos
punetised
Allergia
õietolm
Demographics
Demographics agent Address: Männi 1-2, Tallinn
Discharge letter
Demographics
Mari-Liis
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

23. 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

24. “Have an eExperience in Tallinn”
eHealth Conference in Tallinn October 2010
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).

25. Thank you for your attention. Questions. Madis. Tiik@etervis. ee www
Thank you for your attention! Questions?