Estonia
- Federica Andreoni
- Mohammad Al-Ubaydli
Country’s healthcare system in a nutshell
Estonia's healthcare system, overseen by the Ministry of Social Affairs and managed by the Estonian Health Insurance Fund (EHIF), provides universal coverage, encompassing 94% of the population. The EHIF, funded through general taxation, functions as the primary purchaser of healthcare services, reimbursing providers for contracted treatments. The Ministry also coordinates national health activities such as professional certifications, pharmaceutical quality assurance, and public health initiatives.
In this system, hospitals are mainly owned by the state, local governments, or public legal entities, while primary care centres, pharmacies, and outpatient clinics (unless affiliated with hospitals) are privately owned (World Health Organization, 2024)
According to the most recent data from 2011, health insurance covered 92.9% of the population of Estonia. This coverage encompasses both those who are members of health insurance schemes and those who have free access to state-provided healthcare services (Our World in Data, n.p.)
Public vs private
The pink column refers to the public expenditure as a % of the country’s total healthcare expenditure. The blue dot is the country’s expenditure on health per capita, expressed in international dollars at purchasing power parity.
The national PHR
The e-health system in Estonia is called ‘Estonian nationwide Health Information System’ (EHIS).
https://www.terviseportaal.ee/
EHIS hosts many central registers and databases such as hospitals, family doctors (general practitioners), pharmacies, school nurses, medicine interactions, and different quality registers (cancer, HIV, tuberculosis, etc.). It also utilizes several nationwide registers such as the population and the business register.
EHIS's most widely implemented project is a nationwide health information exchange platform, which is called the nationwide Electronic Health Record (EHR) system.
Functioning very much like a centralized, national database, the e-Health Record retrieves data as necessary from various providers, who may be using different systems, and presents it in a standard format via the e-Patient portal (Metsallik et al., 2018).
History
The evolution of the Estonian e-health system traces its roots back to the initial years of Estonia's independence and is linked to the efforts of its Prime Minister, Mr. Mart Laar, and his team. Mr. Laar held the position of Prime Minister in Estonia during two separate terms, from 1992-1994 and 1999-2002. During these periods, the strategic utilization of information technology was perceived as key for advancing the country's economy. At that time, foundations were laid for numerous initiatives that now constitute the e-state of Estonia, such as, apart from e-health, e-banking, e-documents, e-school, e-taxation, e-voting, and more.
During the initial years of independence, after the Soviet era, Estonia had an underdeveloped information technology infrastructure. In response, there was an evolution in the adoption and integration of information technology across various domains, with a particular emphasis on healthcare.
Between 1990 and 2000, healthcare institutions, including hospitals, general practitioners, and other providers, embarked on the development of proprietary information systems, incorporating electronic health records into their practices. At the same time, several small and medium-sized software companies dedicated to healthcare system development were founded. It was within this decade that informal discussions and preliminary conceptualizations for a nationwide e-health system started.
The e-health system in Estonia, called the Estonian nationwide Health Information System (EHIS) has been launched and operational since the end of 2008.
EHIS was funded by the EU, which contributed €1,196,20, and Estonia, which invested €398,735 (Metsallik et al., 2018).
The scope and magnitude of the digital health infrastructure relies on several partners, partial funding from the European Union, and other organizations inside and outside of the Ministry of Social Affairs - even though the latter is ultimately responsible for it. One such organization, the eHealth Foundation, was formed in 2005 to lead all of the digital health–based projects in Estonia (Willis, 2018).
The most widely implemented e-health project by EHIS is the nationwide health information exchange platform, called the nationwide Electronic Health Record (EHR) system.
For 15 years, the work for the development of digital systems for the country in Estonia has been assigned to a company called Helmes, which has been selected by TEHIK ( a government-owned private company - Estonian Health and Welfare Information Systems Cente). Helmes has been working on:
e-health – digital prescriptions, hospital information systems, central patient administration
central government – state budget management, heading up the shared service center, and self-service interfaces for various agencies
e-voting
e-justice – court management, e-cases
security – e-police, e-prisoner, flight management, border systems
social services – social aid management, unemployment self-service
agriculture – self services, surveillance systems, forest management
utilities – waste management
municipalities – public parking management, public transport management
Nowadays, Estonia is famous for its utilization of a national technical framework in implementing e-government services. The country's digital state services, encompassing vehicle registration, population records, PHRs, banking, energy, telecommunications, and virtually all interactions between citizens and the government, operate through this national infrastructure. What makes the Estonian system an exemplary e-government infrastructure is not only the e fact that every citizen has digital access to services but also the seamless communication and data exchange among these services (Willis, 2018).
Key contributors to the success of Estonia's e-health system include well-defined governance, legal clarity, a mature ecosystem, consensus on access rights, and the standardization of medical data and rules for data exchange (Metsallik et al., 2018).
Architecture and features
As shown in the below image, the EHIS comprises three primary layers: the data layer, the data transfer layer, and the application layer. Within the data layer, there are repositories designated for the storage of medical documents and images. The data transfer layer establishes a secure Internet-based infrastructure to facilitate data exchange between citizens and healthcare providers. The application layer, in continuous development and open-ended in nature, aims to deliver services tailored to the diverse needs of various stakeholders, including citizens, healthcare providers, government authorities, and policymakers, both in the present and future.
EHIS operates as a federated system, characterized by mutually independent yet interconnected healthcare-related software services (Metsallik et al., 2018).
The Estonian e-Health record works as a centralised, national database: it retrieves data from multiple providers (who might be using different systems) and presents them those data in a standardised format on the e-Patient portal.
KSI Blockchain technology is used to ensure the integrity of retrieved electronic medical records as well as system access logs (e-Estonia).
Using the patient portal, the user can:
log in with ID card or mobile ID;
view and update personal data and add contact data of close relatives;
view his/her medical data from healthcare providers;
view electronic referral letters and electronic prescriptions;
add representatives for him/herself for actions such as collecting e-prescriptions;
make declarations of intent (e.g. donation of organs);
access health insurance data;
hide sensitive health data from doctors and representatives;
complete a health declaration form before an appointment;
view the log of who has accessed his/her data.
Challenges and areas for improvement
Researches found that digitalization in healthcare always brings change management issues.
In particular, in Estonia, the difficulties were and are:
Healthcare professionals, to use the e-health portal, had to change the way they filled out medical files toward more uniform language;
difficulty in achieving semantic interoperability of medical data;
challenges persist in ensuring data quality and addressing concerns related to the secondary usage of data;
Some healthcare workers are still reluctant to share medical data with patients on patient portals;
challenges and risks related to ensuring security and electronic authentication of patients (which are mitigated by the use of blockchain technology);
development of the user interface has also been and continues to be a challenge;
low IT skills of part of the population. This is why, for inclusion reasons, patients still have the right to receive their data and services offline.
(Metsallik et al., 2018).
Patients can use the platform to self-enter health declarations, apply for a driving licence, or request a weapons permit; however, they are unable to enter any other health data. The portal’s team states that more services allowing patients to enter data will be added in the near future (PKB interview, 2024).
Patients are also unable to connect their health devices to their records (PKB interview, 2024).
Published outcomes - statistics
Every Estonian citizen that has been to a doctor once, has an online e-Health record. In fact, of 1.3 million citizens, 100% have documents in the central database.
In the e-Health system there are 40 million health documents.
e-Prescriptions cover 100% of the used prescriptions, and, since August 2022, e-Prescription is interoperable with Finland, Portugal, Croatia, and Poland.
Blockchain technology has been adopted to ensure the integrity of health data.
2,5 million queries are made to EHIS by doctors every month.
Research from 2018 showed high usage of the platform by patients, i.e. interest of patients in seeing their own data. According to the paper, this supports the idea that giving patients access to their health data will empower them and encourage them to take a more active role in monitoring their health (Metsallik et al., 2018).
Screenshots
Bibliography
e-Estonia, n.d. e-Health Records. Available at: https://e-estonia.com/solutions/healthcare/e-health-records/ (Accessed 16 July 2024)
Helmes, n.d. Innovative platform improves efficiency of the national population census. Available at: https://www.helmes.com/reference/innovative-platform-improves-efficiency-of-the-national-population-census/ (Accessed 16 July 2024)
Lee, J., Park, Y.T., Park, Y.R. and Lee, J.H., 2021. Review of national-level personal health records in advanced countries. Healthcare Informatics Research, 27(2), pp.102-109. Available at: https://synapse.koreamed.org/articles/1146909
Metsallik, J., Ross, P., Draheim, D. and Piho, G., 2018. Ten years of the e-health system in Estonia. In CEUR Workshop Proceedings, vol. 2336, pp. 6-15. Available at: https://ceur-ws.org/Vol-2336/MMHS2018_invited.pdf
Terviseportaal. Available at: (Accessed 11 July 2024)
Willis, M., 2018. National digital infrastructures for healthcare: A comparative case of Estonian and British healthcare infrastructure. Centre for Technology and Global Affairs. Available at: (Accessed 16 July 2024)
World Health Organization, 2024. Estonia: health system summary 2024. Health System Summary. 20 May 2024. Available at: (Accessed 25 July 2024)
YouTube, 2019. Videopresentation: e-health. Available at: https://www.youtube.com/watch?v=gYzxzzQq2vg (Accessed 16 July 2024)