06.02.2013 4
HEALTHCARE IN
ESTONIA
30 hospitals512 family doctors (juridical persons)
Healthcare expenditures 2011- 5.9% from GDP- 944.6 mlj. EUR
5
Estonian eHealth history
2000 2002 2004 2008
Planning initiated
Project preparation (2003-2005)
2006
Funding decision by Ministry of Economic Affairs
Electronic Health Record
Digital Prescription
Digital Registration
Digital Images
eHealthFoundation established
eHealth Projects (2006-2008)
National HIS18.12.2008
2010
ePrescription01.01.2010
6
Estonian eHealth Foundation• Electronic Health Record (1.6 mln €)
• Digital Registration (0.2 mln €)
• Digital Images (0.2 mln €)
Health Insurance Fund• Digital Prescription (0.24 mln €)
EU funded projects
Standardsdevelopment
ITmanagement
Ministry of Social Affars
East Tallinn Central Hospital
Tartu University Clinic
Society of Family Doctors
North Estonian Regional Hospital
Management board
Estonian eHealth Foundation Board
ENHIS Operation
Estonian Hospital Association
Union of Estonian Medical Emergency
eHealth Foundation organization
Servicesdevelopment
Communicationmanagement
Helpdesk Administrators
Central System – Database and related services • Data set
• Data Standards• Data filters relating
to the central system
• Legal Framework
Data Exchange leveldifferent e-services
• User Interface• User software• Data input• Data Visualisation• Data filters (within user
software)• Web-interfaces• Data transmission
standards (HL7)
Institutional and userlevel cooperation
• Partnerships• User needs• Training programs• Process Descriptions• Notifications
Development levels of Estonian Health Information System
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Standards
• HL7 and DICOM (Picture Archive)
• International classification: ICD-10, LOINC, NCSP, ATC
• Estonian eHealth’s OID registry
• Local eHealth classificators
– Published in publishing centre
– Classificators are regulated by government act https://www.riigiteataja.ee/akt/12910889
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Standardization process
Create data set
Formalize and merge
Approve and publish
Data set document Classificators
Examples
Specialty assotiations
OID-s
XML schemas
Description documents
UML model
Healthcare providers
EeHF standardization
specialists
Social ministry
Stylesheets
UML+HL7 experts
Fixed version of artifacts in
publishing centre
Terminology experts
HIS developers
Health Insurance
Fund
Changes in NHIS documents
regulatory act
12
vi
EHR servicesfor physician
EHR servicesfor patient
Cross Border DataExchange services
Services for SocialInsurance Fund
Digital registrationservices
eConsultationservices
Digital archivingservices
eAmbulanceservices
Digital laboratoryservices
A medicalcertificate services
Data and statisticsservices
Services fordentaal care
Services forblood center
Services forregisters
Services fornurse
Services forhomecare
Health informationservices for patient
E-learning servicesfor medical staff
Analytics services forparticipants in treatment
process
Subservices
Supportingservices
Infrastructureservices
Externalservices
Main services of thee-health in Estonia
13
Major architectural decisions of HIS
• Integration through Central system (Opt-out)
• XML based HL7 v3 (extended) messages
• Documents are kept in XML format (HL7 CDA R2)
• All structured data fields have OID-s
• Only final versions of clinical documents are sent into central system
• Reuse of national infrastructure
– ID card for authentication and digital signature
– Xroad for secure communication
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PHARMACIES AND FAMILY DOCTORS2009
X-Road, ID-card, State IS Service Register
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11
NATION- WIDEHEALTH INFORMATION EXCHANGE PLATFORM2008 december
PRESCRIPTION CENTRE2010 january
PATIENT PORTAL2009
X-ROAD GATEWAY SERVICE2009
Architecture
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The 6 main principles “6 whales” of security of Estonian eHealth system
1. A secure authentication of all users with ID-card or Mobile ID
2. Digital signing or stamping of all medical documents
3. A maximum accountability (transparency): all actions will leave an
unchangeable (and unremovable) secure trail
4. Coding of personal data: separating of personal data from medical
data
5. Encrypted database that allows to remove the confidentiality risk
from the technical administrators
6. Monitoring of all actions together with the corresponding counter-measures (both organizational and technical)
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HIS integration through X-Road
HL7
interaction
HL7 CDA
document
X-Road message
National Central HIS
Digidoc
Healthcare provider IS
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Lab notice
ÜldandmedMari-Liis
47595064059
Männi 1-2
Tallinn
Diagnoospunetised
Allergiaõietolm
Swineflu notice
ÜldandmedMari-Liis
47595064059
Männi 1-2
Tallinn
Diagnoospunetised
Allergiaõietolm
Agents
Timecritical reports
Demographics
Health record
Infection notice
Üldandmed
Mari-Liis
47595064059
Männi 1-2
Tallinn
Diagnoos
punetised
Allergia
õietolm
Discharge letter
Demographics
Mari-Liis
47595064059
Männi 1-2
Tallinn
Diagnosis
chickenpox
Allergy
pollen
Demographics agentAddress: Männi 1-2, Tallinn
Infection disease agentDiagnosis: chickenpox
Timecritical report agentAllergy: pollen
Health record agentEvent: Medication, Diagnosis,
Procedure
Document processing
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Agents
Query
Patient
Mari-Liis
47595064059
Record type
Diagnosis
Health record agentFind all diagnosis type
records
Security agentDocument open?
Consolidate records
Patsient
Mari-Liis
47595064059
Diagnosis
Diagnosis
Diagnosis
Diagnosis: chickenpox
Document no: 103
Hospital: PERH
Warning, some documents are closed!
Query processing
Health record
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Technical solution
• Client systems - HIS, GPIS• Patient portal - Oracle Portal,
2013 change to Tomcat• xRoad Gateway – MISP (Tomcat)• Activity Surveillance - Tomcat,
Sybase IQ, Webfocus• Business Logic - Webmethods
Integration Server and Broker• Data Services - Oracle DBMS with
Advanced Security and Database Vault
• Monitoring - Nagios, Cacti• Statistics –Iway Service Manager,
Sybase IQ, Webfocus
Segmented LAN
Client systems
X-roads security
Business Logic
Data Services
Data Storage
Activity Surveillance
Monitoring
VPN access gate
Portals
Statistics
X-roadgateway
Validation and surveillance data
collection
Client systems withoud Xroad
server
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Acceptance
• ePrescription covers 94% of issued prescriptions.
• Over 90% of Hospital discharge letters – digital
• Over 95% of stationary case summaries have sent to the central DB
• Ambulatory case summaries sending
– No certain rules for sending ambulatory case summaries!
• 1 069 075 person have documents (82% of population)
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ePrescription (94%)
-
100 000
200 000
300 000
400 000
500 000
600 000
700 000
800 000
900 000
1 000 000
ISSUED SOLD
24
Retrieval of Medical Documentsby Healthcare Professionals
0
20 000
40 000
60 000
80 000
100 000
120 000
140 000
160 000
180 000
200 000
Ma
rch
Ma
y
July
Septe
mb
er
No
ve
mbe
r
Janu
ary
Ma
rch
Ma
y
July
Septe
mb
er
No
ve
mbe
r
Janu
ary
Ma
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Ma
y
July
Septe
mb
er
No
ve
mbe
r
Janu
ary
Ma
rch
Ma
y
July
Septe
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er
No
ve
mbe
r
Janu
ary
Ma
rch
Ma
y
July
Septe
mb
er
No
ve
mbe
r
2009 2010 2011 2012 2013
25
Patient portalNumber of queries
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
jaan
.09
mär
ts.0
9
mai
.09
juu
li.0
9
sep
t.0
9
no
v.0
9
jaan
.10
mär
ts.1
0
mai
.10
juu
li.1
0
sep
t.1
0
no
v.1
0
jaan
.11
mär
ts.1
1
mai
.11
juu
li.1
1
sep
t.1
1
no
v.1
1
jaan
.12
mär
ts.1
2
mai
.12
juu
li.1
2
sep
t.1
2
no
v.1
2
jaan
.13
mär
ts.1
3
Number of queries
28
• Resources were planned only for central development.
• Usability. Developing process has to includemedical competence – users
• Data quality is important
– Complete and quality data give value.
• Balance between security and usability
– PIN for every document …
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0
10000
20000
30000
40000
50000
60000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Documents Sent by GPs in 2012 and 2013 (1st Quarter)
Digital stamp for family doctors
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Better services
• Faster data input
– Voice recognition, statistics based text inputassistant
• Faster and better output
– Important information on “one screen”
– Combining information from multiple sources
– Graphical solutions
– Precaching
• Single sign on
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Hospital informationsystem
eHealth centralsystem
Integration platform
RIS / PACS
Notebook
Tablet PC
Mobile
PC
„App Store“