Overview of Estonian Health Information System by Artur Novek on 2019-02-15

1. Estonian
Health Information System
overview
Artur Novek
Health and Welfare Information Systems Centre / IT architect
09.01.2018

2. HWISC is a ICT competence center
founded on 1st of January 2017 which
consolidates the roles and
responsibilities of former ICT department
of Ministry of Social Affairs and Estonian
eHealth Foundation.
Health and Welfare Information
Systems Centre (HWISC)

3. Main responsibilities
• Development of
information
systems,
databases and
e-services
• Maintenance of
services and
infrastructure
• Providing
information
security
• Data analysis to
support policy
making,
reporting,
productivity
monitoring and
supervision

5. HWISC main clients
in the area of Ministry of Social Affaires
HEALTH
SOCIAL
SECURITY
LABOUR
HEALTH BOARD
AGENCY OF MEDICINES
NATIONAL INSTITUTE
FOR HEALTH
DEVELOPMENT
SOCIAL INSURANCE BOARD LABOUR INSPECTORATE
ASTANGU VOCATIONAL
REHABILITATION CENTRE
AREA
ICT
CONSOLIDATED
NON-
CONSOLIDATED
MINISTRY OF SOCIAL AFFAIRS

6. • Gender Equality and Equal
Treatment Commissioner
Agency
• Official Mediator Agency
• Estonian Health Insurance Fund
• Estonian Unemployment
Insurance Fund
Other clients and parties of HWISC
• Other ministries and agencies
• Estonian and EU habitants
• Estonian enterprises
• Local government
• Healthcare providers/hospitals
• ...

7. Estonia
n
eHealth
,
where do
you come
from?

8. 90-s. Local systems, focus on
insurance invoices
1992 1994 1996 2000
Restoration of
Estonian
independence
1998
HIS ESTER in
Mustamäe
hospital
HIS ESTER2
by social
ministry
AS Medisoft
program for
family doctors
2002
Mandatory
electronic bills to
insurance fund
Central health
insurance fund
HIS ESTER3
by social
ministry

9. 2000 – 2010 health information
exchange, focus on health data
2000 2002 2004 2008
Planning of
health data
exchange started
Project
preparation
(2003-2005)
2006
Funding decision by Ministry
of Economic Affairs
Electronic
Health Record
Digital
Prescription
Digital
Registration
Digital
Images
eHealth
Foundation
established
eHealth
Projects
(2006-2008)
National HIS
18.12.2008
2010
ePrescription
01.01.2010
X-road first
services

10. Services
development
IT
management
Ministry
of Social
Affars
East
Tallinn
Central
Hospital
Tartu
University
Clinic
North
Estonian
Regional
Hospital
Society of
Family
Doctors
Management
board
Estonian eHealth
Foundation Board
ENHIS Operation
Estonian
Hospital
Associatio
n
Union of
Estonian
Medical
Emergency
Estonian eHealth Foundation
organization
2005 – 2016 Health IS development and maintenance
Standards
development
Support
(Communication,
accounting, HR, lawyer,
security… )
Helpdesk
Administrators Programmers

11. where
are
you?
Estonian eHealth,

12. Key features of
Estonian healthcare
Area - 45 000 km2
1.33 mlj. Inhabitants
Member of EU since 2004
Euro-zone since 2011
Earmarked social insurance tax
13% flat rate top-up to all salaries
State responsibility for insurance coverage
Single public purchaser of services (Health Insurance
Fund)
2014 94% of population covered
2019 budget 1,45 bln €
Decentralized provider network
Private operators governed mostly by public entities
Strong primary care
Universal free access
>50% of outpatient contacts
Health care expenditures
2014 6.3% from GDP
(EU 10%)
Life expectancy at birth (years)
2015 77,1 years
(EU 81,1)

13. Facts about e-services in Estonia
• 100% of schools and government organizations have
broadband connection
• 99% of bank transfers are performed electronically
• 96% of income tax declarations made in E-Tax Board
(2014)
• 31,7% of votes were cast over the internet on (2017)
• 62% of persons have completed the e-census (2012)
• E-residency program (started 2014)
https://e-estonia.com/

14. Laws that regulate eHealth area
1. Health Care Services Organisation Act;
2. Statute of Health Information System (governments Statute no 131
August 14th 2008);
3. The Statute no 53 September 17th 2008 of Ministry of Social Affairs on
The Composition of Data, Conditions and Order of Maintaining of the
Documents Forwarded to the Health Information System;
4. Data protection law; GDPR;
5. Public Information Act.
• All healthcare providers must send data to Health Information System
• Access only to licensed medical professionals (other persons have access to
personal data in the HIS if such right arises from law)
• ID card for authentication and digital signature
• Patient has the right to close his/her own data collected in the central
database (opt out)
• Patient can access their own data (Patient’s Portal )
• Patient can declare their intentions and preferences
• Patient can monitor visits to their HIS. (All actions will leave secure trail).

15. eHealth services in Estonia Health Insurance Fund
HWISC
Picturebank
Ø EHR services for physician and patient
2008
Ø Cross-border Patient Summary (epSOS)
2013
Ø Health status summary for Social Insurance Board
2012
Ø Digital referrals and registration services
2008
Ø eConsultation services 2012
Ø Digital picture archiving services
2005
Ø Medical certificate services 2014
Ø Health insurance information to healthcare providers
~2000
Ø Collecting health service reimbursement invoices
~1995
Ø Statistics services 2013
Ø ePrescription Services 2010

16. eHealth services in Estonia Health Insurance Fund
HWISC
Picturebank
Ø Drug-drug adverse reactions detection 2016
Ø Health status summary for medical commission of Minstry of Defence
2017
Ø Cross-border e-prescription
2019
Ø Death certificates
2019
Ø Digital registration 2019
Ø Laboratory services management
2019
Ø eAmbulance services 2015
Ø Services for dental care 2015
Ø Services for cancer screening registry
2015

17. Major architectural decisions of
Health Information System
• Integration through Central system
• Opt-out policy in form „patient can close data from
doctors“
• XML based HL7 v3 (extended) messages
• Documents are kept in XML format (HL7 CDA R2)
• All identifiers have OID-s
• Only final versions of clinical documents are sent into
central system after case is closed
• Reuse of national infrastructure
• ID card for authentication and digital signature
• X-road for secure communication
• Personal identification number to identify a person and connect
data in different information systems

18. Estonian Personal Identification Code
ID-code is public
Form: GYYMMDDSSSC
• G - shows sex and century of birth (odd number
male, even number female, 1-2 19th century, 3-
4 20th century, 5-6 21st century)
• YYMMDD - date of birth
• SSS - serial number separating persons born
on the same date
• C - a checksum

19. PHARMACIES
AND FAMILY
DOCTORS
X-Road, ID-card, State IS Service Register
HEALTHCAREBOARD
-Healthcareproviders
-Healthprofessionals
-Dispensingchemists
STATEAGENCYOFMEDICINES
-CodingCentre
-Handlersofmedicines
POPULATIONREGISTER
BUSINESSREGISTER
HOSPITALS
2009
FAMILYDOCTORS
2009
SCHOOLNURSES
2010september
ANONYMIZED
HEALTH DATA
FOR STATISTICS
2013NATION- WIDE
HEALTH
INFORMATION
SYSTEM
2008 december
PRESCRIPTION
CENTRE
2010january
DOCTOR
PORTAL
2013
X-ROAD
GATEWAY
SERVICE
2009
Estonian eHealth architecture
PATIENT
PORTAL
2009 v1
2013 v2
SOCIAL
INSURANCE
BOARD
PORTAL
2012
HEALTHINSURANCE
FUNDREGISTER
AMBULANCE
SERVICES
APPLICATION
2014
STATISTICS
PORTAL 2013
EMERGENCY
SERVICE MOBILE
WORKSTATIONS
Drug-drug
Interaction
database
2016
NATION-WIDE
PICTUREARCHIVE
2005(national2014)
VPN
QUALITYREGISTERS
Cancer.HIV.Myocardialinfarction.
Tuberculosis.etc.

20. eHealth copies e-state architecture

21. Message layers on X-Road
HL7
interaction
HL7 CDA
document
X-Road message
National Central HIS
Digidoc
Healthcare provider IS

22. Lab notice
Üldandmed
Mari-Liis
47595064059
Männi 1-2
Tallinn
Diagnoos
punetised
Allergia
õietolm
Swineflu notice
Üldandmed
Mari-Liis
47595064059
Männi 1-2
Tallinn
Diagnoos
punetised
Allergia
õietolm
Agents
Timecritical reports
Demographics
Medical events
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 agent
Address: Männi 1-2, Tallinn
Infection disease agent
Diagnosis: chickenpox
Timecritical report agent
Allergy: pollen
Health record agent
Event: Medication, Diagnosis,
Procedure
Document processing
Patient index
Medical documents
Medical documents receiver agent
Document: Lab notice, Discharge
letter
Patient coding agent
Find or create patient
internal code

23. Data in Health Information System
Document
registry
Patient index
Patient
identity
Subject
Identity 1
Medical documents
Consultation
note
Version 2
Image
reference
Epicrisis
Version 2
Referral Referral answer
Identity 2
Identity 3
Demographics (alternative sources)
Patient
portal
Version 1
Version 2
Version 3
Population
registry
Medical
documents
Lasting care, diagnosis, observation
Pregnacy Diagnosis Blood group Allergy
Status 1
Status 2
Status 3
Status 4
Medical events
Diagnosis
Version 2
Operation Visit
Version 2
Prescription Procedure
Status 1
Status 2
Status 3
Status 4
Status 1
Status 2
Status 3
Status 4
Status 1
Status 2
Status 3
Version 1 Version 1
Version 1 Version 1 Version 1
Version 1 Version 1 Version 1

24. AgentsQuery
Patient
Mari-Liis
47595064059
Record type
Diagnosis
Health record agent
Find all diagnosis type
records
Security agent
Document open?
Consolidate records
Patsient
Mari-Liis
47595064059
Diagnosis
Diagnosis
Diagnosis
Diagnosis: chickenpox
Document no: 103
Hospital: PERH
Warning, some documents
are closed!
Query processing
Medical events
Patient index
Access rights
Patient coding agent
Find patient internal code

25. Technical solution
• Client systems – Hospital IS, GP
IS
• Patient portal Tomcat
• xRoad Gateway – 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 - Zabbix
• Statistics – IWay Service
Manager, Sybase IQ, Webfocus
Segmented LAN
Client systems
X-road
X-road
security
Business
Logic
Data Services
Data Storage
Activity
Surveillance
Monitoring
VPN access
gate
Portals
Statistics
X-road
gateway
Validation and
surveillance data
collection
Client systems
without Xroad
server

26. SECURITY & AUTHENTICATION

27. The 6 main principles “6 whales” of security
of Estonian Health Information 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, protected by blockchain
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)

28. Acceptance
• ePrescription covers 100% of used
prescriptions. 98% are prescribed digitally,
remaining 2% are entered in pharmacy.
• 97% of Hospital discharge letters are sent to the
central DB.
• 60% of ambulatory case summaries
• 60% of dental care summaries are digital and
sent to the central DB
• 1,4 mln person have documents in cetral DB

29. ePrescription
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
jaan.10veebr.10m
ärts.10apr.10m
ai.10juuni.10juuli.10aug.10sept.10okt.10nov.10dets.10jaan.11veebr.11m
ärts.11apr.11m
ai.11juuni.11juuli.11aug.11sept.11okt.11nov.11dec.11
jan.12feb.12m
ar.12apr.12m
ay.12
ISSUED SOLD

30. Documents and events in HIS
01.07.2018
Document type Count
Ambulatory case summary 21 227 979
Refferral answer 10 867 804
Dental card 2 893 644
Referral 2 226 691
Hospital case summary 1 924 799
Immunization notification 853 228
Ambulance card 615 852
Children health check
notification 585 560
Health certificate 369 112
Day-care case summary 352 158
Home nursing summary 9 442
Total 41 926 269
Event type Count
Procedure 195 576 766
Analysis 91 320 074
Diagnosis 44 437 888
Visit 43 905 679
Case 28 266 067
Observation 21 611 242
Anamnesis 20 765 924
Immunization 2 185 457
Hospitalization 1 838 705
Surgery 867 763
...

31. HIS usage per month
0
500000
1000000
1500000
2000000
2500000
3000000
2008.12
2009.03
2009.06
2009.09
2009.12
2010.03
2010.06
2010.09
2010.12
2011.03
2011.06
2011.09
2011.12
2012.03
2012.06
2012.09
2012.12
2013.03
2013.06
2013.09
2013.12
2014.03
2014.06
2014.09
2014.12
2015.03
2015.06
2015.09
2015.12
2016.03
2016.06
2016.09
2016.12
2017.03
2017.06
2017.09
2017.12
2018.03
2018.06
Patient queries per month Healthcare professional queries per month Documents per month

32. European Hospital Survey:
Benchmarking Deployment of е-Health Services
2012
The Availability and Use Composite Indicator
https://ec.europa.eu/digital-single-market/news/european-hospital-survey-benchmarking-deployment-ehealth-

33. Estonian eHealth,
where
do you
get the
money?

34. Health Information System’s financing
through eHealth Foundation
Ministry of
Social Affairs
Taxes
Health Insurance Fund
Healthcare Provider
eHealth Foundation
Ministry of
Economic Affairs and
Communication
EU Funds
64%12% 201324%
Without EU financing 1/3 from HCP-s and 2/3 from Social Ministry
Year Expenditure (€)
2005 6 853
2006 259 944
2007 462 193
2008 1 009 156
2009 1 178 362
2010 1 433 602
2011 1 834 204
2012 2 504 797
2013 2 863 162
2014 3 223 829
2015 3 647 354
2016 3 282 922
In total 21 706 378

35. Estonian eHealth Foundation
• Electronic Health Record (1.6 mln €)
• Digital Registration (0.2 mln €)
• Digital Images (0.2 mln €)
• Activity surveillance module (0.4 mln €)
• Statistics module (0.4 mln €)
• Authentication and authorization module (0.2 mln €)
• eLaboratory (0.2 mln €)
Health Insurance Fund
• Digital Prescription (0.24 mln €)
EU funded projects

36. Thank You!
Artur Novek
artur.novek@tehik.ee