Estonia
- Federica Andreoni
- Mohammad Al-Ubaydli
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 provides universal coverage. The government is payer and provider for most of health care.
The Ministry of Social Affairs manages the Estonian Health Insurance Fund (EHIF). EHIF is funded through general taxation and is the primary buyer of healthcare services. The Ministry also coordinates national health activities such as professional certifications; pharmaceutical quality assurance; and public health initiatives.
Hospitals are mainly owned by the state, local governments, or public legal entities. Primary care centres, pharmacies, and outpatient clinics (unless affiliated with hospitals) are privately owned (World Health Organization, 2024).
92.9% of the population is covered by health insurance. This includes members of health insurance schemes and those with 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). The Ministry of Social Affairs is responsible for it.
EHIS hosts central registers and databases, including those for hospitals, family doctors (general practitioners), pharmacies, school nurses, and medication interactions. It also hosts quality registers (such as cancer, HIV, and tuberculosis). It uses several nationwide registers, including the population and business registers.
The nationwide health information exchange platform is referred to as the nationwide Electronic Health Record (EHR) system. EHIS’s EHR retrieves data to show in a standard format in the e-Patient portal, named Terviseportaal (Health Portal) (Metsallik et al., 2018). Data is from health care providers, who may be using different internal systems.
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.
There was a strategic emphasis on healthcare. Between 1990 and 2000 healthcare institutions 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. During this decade discussions and conceptualisations for a nationwide e-health system began.
EHIS has been operating since 2008. The European Union contributed €1,196,200 and Estonia €398,735 to launch it (Metsallik et al., 2018). The eHealth Foundation was formed in 2005 to lead all digital health-based projects in Estonia (Willis, 2018).
Helmes, a private company, has managed the development of digital systems in Estonia for the past 15 years. The government’s TEHIK (the Estonian Health and Welfare Information Systems Centre) selected Helmes. 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 cover other sectors such as government, e-voting, e-justice, and security, to support the overall digital infrastructure of the country (Helmes, n.d.)
What makes the Estonian system an exemplary e-government infrastructure is the seamless communication and data exchange among so many comprehensive 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
EHIS has three layers: data, data transfer, and application. The data layer stores medical documents and images. The data transfer layer securely moves data over the internet between citizens and healthcare providers over the internet. The application layer delivers services and is in continuous development. It is tailored to the diverse needs of various stakeholders, including citizens, healthcare providers, government authorities, and policymakers.
EHIS is a federated system: healthcare-related software are independent and interconnected (Metsallik et al., 2018).
The EHR centralises data retrieval from providers and standardises presentation 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).
The patient portal’s users can:
Log in using an ID card or mobile ID.
See and update personal information and add contact details for close relatives.
Access their medical data from healthcare providers.
See referral letters and prescriptions.
Authorise representatives for actions such as collecting e-prescriptions.
Declare intention e.g. organ donation.
Access health insurance data.
Hide sensitive information from doctors and representatives.
Complete a health declaration form prior to an appointment.
See a log of who has seen their data.
Challenges and areas for improvement
The development and implementation of the system faced several challenges, including:
Resistance to Change: Healthcare professionals were resistant, particularly in adopting a more standardised language for recording medical information in the e-health portal.
Reluctance to Share Data: Some healthcare professionals were hesitant to share medical data with patients through the portal.
Data Quality: Ensuring consistent and accurate data entry is a continuous challenge.
Semantic Interoperability: Standardising medical terminology to achieve semantic interoperability of medical data is an ongoing effort.
Security and Authentication: Ensuring robust security and electronic patient authentication is critical; blockchain technology has been instrumental in addressing this.
Privacy Concerns: Users are concerned about potential secondary use of their data.
User Interface Development: ensuring the usability and accessibility of the portal has been challenging and remains a priority.
Digital Skills: A segment of the population lacks sufficient IT skills. To promote inclusivity, patients retain the option to keep accessing their data and services offline.
In terms of features, key areas for improvement include:
Patient Data Entry: Patients currently cannot input their own health data into the portal. The development team plans to enable this functionality in the near future.
Device Integration: Patients are unable to connect personal 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. 100% of Estonia’s 1.3 million citizens have documents in the central database, 40 million documents in total. 100% of prescriptions issued are electronic. Since August 2022, the e-Prescription system has been interoperable with those in Finland, Portugal, Croatia, and Poland.
Doctors query EHIS 2.5 million times a month (e-Estonia, 2024).
Patients usage is high, demonstrating significant interest in accessing 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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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 (accessed 3 Novemer 2024).
Terviseportaal. Available at: https://www.digilugu.ee/login?locale=en (accessed 11 July 2024).
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