Overview of Estonian Electronic Health Record (EHR) System

During the last decade, Estonia became well known as a country with advanced e-services, not only in the business sector (especially banking), but also in e-Government services (electronic tax board, state commercial, car and shipping registers, e-voting, e-school, e-ticket etc.). The state has already established and maintains a nationwide technical infrastructure called the X-road platform. X-road is a platform independent standard interface for secure data processing, connection of all Estonian public sector databases and information exchange. Other IT-solutions such as digital signatures and ID-card authentication are recent innovations, and their use is comprehensively regulated by national law. These developments are the basis of implementing sectoral policies such as creating a countrywide electronic health record.

The idea of eHealth and electronic health record already emerged in 2002. The purpose was to develop a nationwide framework (database) to facilitate the exchange of digital medical documents and diffuse health information available so far only in local databases and information systems that were not able to communicate with each other. In 2005, as the recipient of the structural aid, the Estonian Ministry of Social Affairs launched a new e-health concept by phasing in four projects: Electronic Health Record, Digital images, Digital Registration and Digital Prescription (eHealth projects). The result of implementing eHealth projects is the Electronic Health Record that was launched on December 17th 2008.

The main goals for starting the eHealth projects were the following: -Decreasing the level of bureaucracy in the doctors work process -Increasing the efficiency of the health care system -Making the time-critical information accessible for the attending physician -Developing health care services that are more patient friendly and have higher quality

Management

The eHealth projects were complex multi-annual projects involving a number of partners. The Ministry of Social Affairs fulfilled the coordinating and directing rule in implementing the eHealth projects. As the eHealth projects were not just a large IT projects, but social development projects involving a large partnership. Alongside implementation of new information technology concepts, it also includes other aspects, such as medical standardisation, ethics and legislation. To ensure effective management of the eHealth projects the Estonian E-Health Foundation was established in 2005 by the Ministry of Social Affairs and several other healthcare providers for leading the four eHealth projects.

The gradual development of the system will continue until 2013. According to the Health Information System Statue (July, 2008), the processor of the EHR is the Ministry of Social Affairs and the authorized processor of the EHR is the Estonian eHealth Foundation.

Today the Foundation has 20 employees, including 3 service-desk analysts, an assistant, information security manager, standardization and classification specialists, information system manager, IT-development, service and HIS implementation managers, communications manager, 2 project managers for continued development (e.g. the eParamedics project), international project's manager, procurement manager, an accountant, financial manager and one member of the Management Board.

Data Usage

The Health Services Organization Act and Associated Acts Amendment Act accepted by the Estonian Parliament (the Riigikogu) on December 20th of 2007 provides that as of September 1st of 2008 the health care service providers are obligated to forward medical data to the EHR. The rules for data usage state that only the health care employee currently associated with patient's treatment has the right to make enquiries about patient's data, i.e. the patient's attending physician or a medical assistant. Making enquires about patient's health data outside of treatment process is not allowed. Health data will be issued to health care employees registered with Health Care Board and who are marked as the attending physician.

Patients can use the Patient's Portal to exercise their right to set restrictions of access to their health data. In this case the patient will be informed by information system at the time of setting the restriction that it is dangerous to his/her life and health to provide health care services based on insufficient information. There will be no access allowed to initial documents even in the emergency situation and the patient will take full responsibility regarding possible consequences that may arise from banning access to data.

EHR in Numbers

Gathering of the data began on December 17th 2008 and by March 2010 the EHR contains over a million medical documents. For the moment the agreed amount of data is sent to the system, containing discharge letters (inpatients and outpatients), referrals and links to digital images.

To effect their legally binding obligation to send medical documents to the information system over a thousand health care providers out of the total 1021 licensed in Estonian Health Care Board have signed the contract with Estonian eHealth Foundation who is the authorized processor of the EHR. 309 of them are by now participating in the actual data exchange. This may seem a small number but we have to take into consideration first the size of the country, and second the fact that the implementation of a system this large will take its time.

Document Type 2009 Jan. 2010 Feb. 2010 Mar. 2010 Apr. 2010 May 2010 Jun. 2010 Jul. 2010
Medical Documents 350 622 572 634 909 035 1 103 981 1 120 183 1 421 383 1 596 902 1 685 618
Inpatient Discharge Letters 63 486 73 065 88 267 131 329 145 940 178 021 193 725 209 513
Outpatient Discharge Letters 81 275 98 026 124 135 153 581 191 298 226 490 262 257 292 541
Daycare Discharge Letters 1 066 1 506 2 090 2 604 3 073 3 631 4 102 4 477
Links to digital images 121 748 136 213 155 578 177 637 186 281 205 120 220 823 236 569
Referrals 231 238 272 307 342 392 425 493
Referral’s answers 82 827 94 741 110 560 128 916 139 474 156 247 170 618 195 676
Birth Discharge Letters - - - 31 356 762 960 1293
ePrescriptions
(launched in 01.01.2010)*
- 276 965 401 387 509 576 453 419 650 672 743 944 745 004
Dispensed medication information - 149 990 221 630 193 094

*Note: all of the ePrescription’s information has not been sent to the central system starting from March.

The Patient's Portal which was launched in 26th of October 2009 enables the patient to access his/her medical data irrespective of time and place. By April 2010 there has been 13 426 individual visits to the portal and 228 494 enquiries has been made by the patients.

Innovation Results of EHR The most innovative technological aspect is that implementation of the EHR does not cause massive re-engineering of the existing in-house information systems and communication infrastructure, which will just be integrated ("linked") by special system modules. The message exchange module (the so-called agent centre) enables data exchange and interoperability of all integrated users and delivers all messages which conform to the standard message type.

Providing the users (medical personnel or patients) with message exchange and administration, the agent centre makes possible several rights and services, which make the system user-friendly:

  1. central security solution,
  2. administration of rights and users,
  3. authentication and authorisation of users,
  4. integration with external information systems (via X-road),
  5. message administration and message-based integration,
  6. log-in (for example, for the online Patient Portal).

Transferability

The Estonian EHR is globally unique which encompasses the whole country, registers virtually all residents' medical history from birth to death, and is based on the comprehensive state-developed basic IT infrastructure.

This concept of a nationwide integrated EHR system covering the whole population is fully transferable only if all of the following preconditions are fulfilled: first, the existence of a nation-wide secured data-exchange platform; secondly, the application of the highest security standards for system accessibility and users' authentication, signature and encryption; thirdly, enforcement of the national laws for collection and exchange of personal medical data. It is evident that implementation costs may differ case-by-case, but it is assumed that such a project should be based on the results of comprehensive feasibility studies.

Last updated on 31st of August 2010