Estonia

Owned by Federica Andreoni
Last updated: Nov 04, 2024
8 min read

Estonia is Europe’s biggest creator of billion dollar tech companies per capita (Atomico 2022). This private sector excellence started with the public sector investing in technology. Its post-independence government mandated computer programming for every child in school in 1997.

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

Health care spending by country in 2021 (1).svg
Source: The World Bank.
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).

EHIS hosts numerous central registers and databases, including those for hospitals, family doctors (general practitioners), pharmacies, school nurses, medication interactions, and various quality registers (such as cancer, HIV, and tuberculosis). It also utilises several nationwide registers, including the population and business registers.

The most widely implemented project within EHIS is a nationwide health information exchange platform, referred to as the nationwide Electronic Health Record (EHR) system.

Functioning much like a centralised national database, the EHR 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, named Terviseportaal (Health 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 utilisation 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.

In the initial years following independence from 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 developing proprietary information systems that incorporated 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 conceptualisations for a nationwide e-health system began.

(EHIS), has been launched and operational since the end of 2008. EHIS was funded by the EU, which contributed €1,196,200, while Estonia invested €398,735 (Metsallik et al., 2018).

The scope and magnitude of this digital health infrastructure rely on several partners, with partial funding from the European Union and other organisations inside and outside the Ministry of Social Affairs, which is ultimately responsible for it. One such organisation, the eHealth Foundation, was formed in 2005 to lead all digital health-based projects in Estonia (Willis, 2018).

For the past 15 years, the development of digital systems in Estonia has been managed by a company called Helmes, selected by TEHIK (the Estonian Health and Welfare Information Systems Centre). Helmes has played a key role in advancing the e-health sector, including the implementation of digital prescriptions, hospital information systems, and central patient administration. Their contributions extend beyond healthcare, encompassing various sectors such as government, e-voting, e-justice, and security, all of which support the overall digital infrastructure of the country.

For 15 years, the development of digital systems for the country in Estonia has been assigned to a company called Helmes, which was selected by TEHIK (the Estonian Health and Welfare Information Systems Centre, a government-owned private company). Helmes has played a key role in advancing the e-health sector, including the implementation of digital prescriptions, hospital information systems, and central patient administration. However, the company's contributions extend well beyond healthcare. Helmes has in fact also developed digital services in areas such as central government budget management and self-service interfaces for various agencies, e-voting, e-justice, security (including flight management and border systems), social services (such as social aid management and unemployment self-service), agriculture (including surveillance systems and forest management), waste management, and municipal services (such as public parking and public transport management). Collectively, these initiatives support the overall digital infrastructure of the country.

(Helmes, n.d.)

Nowadays, Estonia is famous for its utilisation of a national technical framework in implementing e-government services. The country's digital state services encompass vehicle registration, population records, PHRs, banking, energy, telecommunications, and virtually all interactions between citizens and the government. What makes the Estonian system an exemplary e-government infrastructure is not only the 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 standardisation 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, which is 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.

EHIS operates as a federated system, characterised by mutually independent yet interconnected healthcare-related software services (Metsallik et al., 2018).

PKB_Book Cover and Slides_20240815.pptx (3).png
Metsallik et al., 2018

The Estonian e-Health Record functions as a centralised national database, retrieving data from multiple providers—who may be using different systems—and presenting that information in a standardised format on the e-Patient portal.

Keyless Signature Infrastructure (KSI) Blockchain - a unique blockchain technology invented in Estonia - is used to ensure the integrity of retrieved electronic medical records as well as system access logs (e-Estonia).

Through the patient portal, users can:

  • Log in using an ID card or mobile ID.

  • View and update personal information and add contact details for close relatives.

  • Access their medical data from healthcare providers.

  • View electronic referral letters and prescriptions.

  • Authorise representatives to perform actions such as collecting e-prescriptions.

  • Make declarations of intent (e.g. organ donation).

  • Access health insurance data.

  • Conceal sensitive health information from doctors and representatives.

  • Complete a health declaration form prior to an appointment.

  • View a log of who has accessed their data.

 

 

 

 

 

 

Challenges and areas for improvement

Research has identified that digitalisation in healthcare often brings about change management issues. In Estonia, the challenges include:

  • Change resistance among healthcare professionals, particularly the need for them to adopt a more uniform language when completing medical records for the e-health portal. Moreover, some healthcare workers remain reluctant to share medical data with patients through these portals.

  • Difficulties in achieving semantic interoperability of medical data.

  • Ensuring the security and electronic authentication of patients - which are mitigated through the use of blockchain technology.

  • Ensuring data quality and addressing concerns related to the secondary use of data.

  • Difficulties in developing the user interface.

  • A segment of the population lacking sufficient IT skills. To promote inclusion, patients retain the right to receive their data and services offline.

  • (Metsallik et al., 2018).

 

 

 

 

 

 

Patients can utilise the platform to self-enter health declarations, apply for a driving licence, or request a weapons permit; however, they cannot input other health data. The portal’s team has stated that more services allowing patients to enter data will be added in the near future. Additionally, patients are currently unable to connect their health devices to their records (PKB interview, 2024).

Published outcomes - statistics

Every Estonian citizen who has visited a doctor at least once has an online e-Health record. In fact, of 1.3 million citizens, 100% have documents in the central database.

The e-Health system contains 40 million health documents. e-Prescriptions account for 100% of prescriptions issued, and since August 2022, the e-Prescription system has been interoperable with those in Finland, Portugal, Croatia, and Poland.

Doctors make 2.5 million queries to EHIS each month (e-Estonia).

Research from 2018 indicated high usage of the platform by patients, demonstrating significant interest in accessing their own data. This supports the notion that providing patients with access to their health information empowers them and encourages a more active role in monitoring their health (Metsallik et al., 2018).

Screenshots

Bibliography

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