National eHealth

Solutions from Estonia

DR.PEETER ROSS
DR.MADISTIIK
6.11.2008

Content of presentation
• e-Estonia
• eHealth Foundation
• Health information system
• eHealth services created using integration platform
• e-prescription
• e-ambulance
• e-registration to appointment
• e-images
• e-school
• Health care providers´ view
• Lessons learned

e-Estonia
• Wide range of e-services
– e-election
– e-tax board
– e-school
– e-commercial registry, etc
• High bandwith connectivity
– Internet
• 66% of population use regulary internet (2007)
• 1169 Free public Wifi services in all over Estonia
• The whole territory of Estonia is covered with
possibility of dedicated links
 X-road
• Aggregates 80 different databases
• 1500 e-services
• 500 different organizations have integrated
their systems into X-road
• Services of X-road were used 42 000 000
times a year (2007)

DATABASES / INFORMATION SYSTEMS BANKS

• SEBbank
Register

Insurance Register

Vehicle Register

Tallinn Water IS
Population register

Health Insurance

National Pension

Estonian Energy IS

• Swedbank
• Creditbank
• Sampo Bank
• Nordea Bank

Security Security Security Security Security Security Security

Server Server Server Server Server Server Server

Internet - X-tee

Security
Server
Security
:: … ::
Server Central server I Monitoring
E-institution – Institution view
http://www.riik.ee/arr/

National Databases
register

:: E-county – county view ::

:: E-riik – State Portal :: Central server II Helpdesk ID – card

Institutional view of the state Thematic view of the state
www.riik.ee www.eesti.ee

KIT EIT AIT

Citizen view Enterpriser view Public servant view X-road certification centre

Tools centrally developed by the State X-road Center Certification Center

eHealth Foundation
• Founded 18.10.2005
• Founded by main health care stakeholders
– 3 largest hospitals – North Estonia Regional
Hospital (NERH), Tartu University Hospital (TUH),
East Tallinn Central Hospital (ETCH)
– Ministry of Social Affairs
– The Estonian Society of Family Doctors
– The Estonian Hospitals Uninon
– The Assossiation of Ambulance doctors
Team of 15 members
• 3 project managers
– 1 EU project
– 1 Standardization
– 1 New projects and international collaboration
• 3 IT managers
– IT service manager
– IT development manager
– IT application maintenance manager
• 3 Helpdesk analysist / first level service desk
• 1 Security specialist
• Assistant, accountant, finance/personel, PR, CEO

Our tasks
• Project management of EU projects
• Standardisation and developing digital documents
• Maintanance of the Estonian eHealth system
“Digilugu”
• International cooperation, scientific cooperation with
universities
• Develop new services for citizens and doctors

Financed from the State budget (1.2 mln € - 2008)

HEALTH CARE BOARD

- Health care providers
- Health professionals - Company registry East Tallinn Tartu Emergency
- Dispensing chemists Central Hospital Medical Service

STATE AGENCY
OF MEDICINES Tartu University North Estonian Järveotsa Family
- Coding Centre - Citizen Registry Hospital Regional Hospital Health Center
- Handlers of medicines

TS TS TS TS TS TS TS TS TS

X-ROAD
TS TS TS
TS

Patient portal Doctor’s Portal Monitoring portal

MISP HEALTH INSURANCE

-Registry of rights of FUND
Goverment’s e-service framework health care professionals
www.eesti.ee Prescription Centre

KIT EIT AIT

Citizen view Employer view Official’s view
Doctor’s and farmacies HEALTH INFORMATION
software solutions SYSTEM
- Electronic Health Record
- Digital Image
- Digital Registration
 e-prescription
• General principles of prescribing and selling
medicines in Estonia will not change
• Prescription Centre is established
• Every doctor will compile a digital prescription
and forward it to the central Prescription Centre
• Automated suggestion of correct reimbursement
level
• Any pharmacy can access the Prescription
Centre according to granted authority and enter
data regarding the purchase to the Prescription
Centre

e- registration to appointment
• Referral Centre is launched
• Every service provider forwards the referral
to the Referral Centre
• Referral based additions to waiting list can
be made by the doctor, the person to be
added or an employee of the registration
• There will be a national central waiting list
– At first out-patient appointments
– Future potential to expand to diagnostical procedures and
in-patient appointments

e- images
• Images are stored in central PACS
• DICOM format is used
• The images are made accessible centrally
by adding a link of the image archive to the
central system since 01.11.2008
• Image can be viewed through the system,
processing depends on the workstation of
the doctor
• Other images (non-DICOM) and multimedia
files will be stored from 2010
 e-school medicine – as an example
for future development process
• Standardised documentation for school nurses
• Ready 2007 (eHealth Foundation)
• End-user application for school nurses
• Procurement made by Tallinn city – ongoing, ready
spring 2009, piloting since 2009 autumn, in Tallinn.
• From 2010 obligatory for all school heathcare
providers
• Central “agent” for handling documentation
• New services for the Patient portal
• Spring 2009 (eHealth Foundation)

Health care providers´ view

• Hospital
• Other health care providers
– General practitioners
– Other hospitals
– Customers
• Patient

East Tallinn Central Hospital

• Founded in 1785
• Municipality owned legal entity since 2001
– Established by merging 7 separate health care
institutions
• 4 hospitals
• 2 policlinics
• 1 diagnostic centre
East Tallinn Central Hospital
• Current situation (2007)
– 6 clinics
• Clinic of Internal Medicine, Clinic of Obstetrics
and Gynaecology, Clinic of Long Term Care,
Clinic of Surgery, Diagnostic Clinic, Eye Clinic
– ca 1700 employees
• 270 doctors, 670 nurses and 290 assistants
– Turnover – 46 mio EUR (2007)

East Tallinn Central Hospital

• Located in 5 remote locations in Tallinn
• 550 beds (incl 433 active care beds)
• Hospital covers the most of the specialities
– lacking only neurosurgery, cardiac surgery, nephrology,
haematology, child diseases and psychiatry
• Patients hospitalised annually
• 2003 – 25 856; 2005 – 25 894; 2007 – 28 547
• Outpatient visits annually
• 2003 – 373 443; 2005 – 425 450; 2007 – 453 518

East Tallinn Central Hospital

• Hospital Information System (HIS)
– Implemented in 1992, renewed 2003
– HIS integrates all five remote buildings
– Today all electronic patient record figures except
diary
– Picture Archiving and Communication System
since 2003 for radiology
– Patient portal since February 2008
 Current development of IT
• Electronic Patient Record (EPR),
• Clinical Information
System (HIS) • Radiology IS (RIS), Laboratory IS (LIS),
• Pathology IS (PIS), etc.

• Only soft copy reading

• Picture Archiving & • Connected to nationwide Estonian PACS
Communication System
• eReporting (remote reporting)
(PACS)
• EPR is open for General Practitioners
• Networking
• EPR is open for a citizen
• Connected to Baltic eHealth network

CIS and PACS integration

• CIS and PACS integration

– Web based CIS
• Accessible for
– Hospitals specialists and doctors
– General practitioners and doctors outside the hospital
– Patients

HIS and PACS integration

Electronic
Communication and Identification layer

Patient
Firewall

Patient
Patient
database
Patient Record General
database
Patient
database Hospital practitioner
Patient
database
database user
Stationary Citizen
care
Integrated CIS Ambulatory X-road
care
Web Diagnostic X-road certification centre
Image based
archive PACS Images
Strea- PACS ID – card
ming integration
iPatient
 Access to Estonian health
information system
• Functions of CIS remained unchanged
• No additional training for personnel needed
• ID card to identify the user
• Cross institutions services
– Epicrisis
– Image link
– Referral letter
– Prescription

Access with ID card

Physicians desktop
Referral letters in central system

General Practitioners access to

hospital information system
• Web access
• Entitled to access patients only from his/her
patient list
• ID card to identify the user
• Access to all electronic data stored in
hospitals clinical information system
– Text files
– Laboratory test results
– Images
Lessons learned
• agreement of standards before the start
of the implementation
• preparation of proper legal environment
including strict rules for patient delicate
data handling
• involvement of the main stakeholders
• reuse already working IT solutions made
by State
– ID card
– X–road
 Lessons learned
• First nation wide, complex eHealth
platform for e-health services with low
cost
– EU structural funds 2006-2008 (3.2 mio €)
– State budget 2006-2008 for eHealth
Foundation (2.0 mio €)
– Health care providers 2006-2008 (1.5 mio €)

Thank you for your attention!