The Estonian e-health solution is quite unique in the world as it can be used not only by all healthcare professionals and patients, but its users also have the option of granting others access to their e-health data. People can, for example, provide access to the medical committees of the defence forces or the public road administration, or in order to have a disability attested.
This Ministry of Social Affairs of Estonia blog post (Estonian) was written by Data Architect and Head of Standardisation Mari Asser, of the Health and Welfare Information Systems Centre.
General practitioners and specialist doctors in Estonia upload diagnoses, analyses and test results as well as treatment decisions and prescribed medicines, etc. to a central national database – the health information system. In an emergency situation, first-response ambulance personnel compose an electronic first-aid card in the ambulance itself. If the patient can be identified during the emergency situation, the first aid personnel already has access to all of the information that is available on the patient in the health information system.
All doctors and nurses practising in Estonia have the legal obligation to enter treatment related information in the health information system. This applies both to the visits covered by the Estonian Health Insurance Fund as well as to those paid by the patient.
How does the data exchange work?
It is mainly universal data transfer formats that are used in Estonia, regardless of the type of doctor preparing the data or the medical condition described. The ambulatory epicrisis, which contains a summary of a visit or treatment, is what is most often entered. Doctors can also draw up electronic referrals or referral responses. All of the information must be entered into the central information system within one (ambulatory reception) or five (hospitalisation) working days, as stated in the law.
There is a standard in use for data exchange, which means that on one hand, there is an agreement between the state and doctors on what information needs to be uploaded about specific treatment processes and, on the other, the standard works as an information technology language. Thus, the data is comprehensible to the information system and can be processed (i.e. it is machine readable) and, if need be, the data can also be used in other e-services offered by the state. In Estonia, the Information Centre for Health and Wellbeing (Tervise ja Heaolu Infosüsteemide Keskus) is responsible for the standards of use.
The process is organised so that data only needs to be entered once, each doctor in Estonia uses their own information system – of which there are around 20 being used by Estonian hospitals, general practitioners, and specialists doctors. Medical practices that don’t have their own information system can use the doctors’ portal developed by the state (Arstiportaal). From the doctors’ information systems, the patients’ data are transferred via a secure X-road to the central health information system, where the information is accessible to both the doctor and the patient.
Who can see what data?
In Estonia, the rule is that health records are open by default, which means that healthcare professionals can ask for data unless the patient has made their data inaccessible in the system. Healthcare professionals have the right to ask for data when they have an ongoing treatment relationship with the patient. A treatment relationship begins when a patient registers to an appointment or when a patient receives first aid care. The treatment relationship ends, in regard to e-health, when the healthcare professional has finished working with the patient’s documents and the information has been entered into the health information system, after being approved.
Doctors can also ask for information uploaded by other doctors, regardless of the speciality of the doctor or nurse. Thus, a dentist can see an ambulance card and a gynaecologist has the option to see a dental card, should this information be important to helping a patient.
Doctors and nurses have an ethical obligation to assess whether making data enquiries is justified. At the same time, doctors have found that having a complete overview of a patient’s condition helps make better treatment decisions, since the data of one speciality can also be decisive in the treatment decision of a doctor in another speciality.
Patients hold the information and have the right to decide
Patients can see all of their information in the national patient portal, including who has viewed the health data (and what data) about them in the information system. Patients can also see what invoices have been forwarded to the Estonian Health Insurance Fund by their health professional. Therefore, the system is transparent and allows everyone to check how much their treatment has cost.
People can see the same medical data that the doctors and nurses can see, such as overviews of a diagnosis, tests, operations details and digital prescriptions. At the moment, medical images cannot be viewed, but all referral responses related to the images are still accessible to the patient.
The patient portal can be accessed with a Mobile ID or an ID card. In addition to the option to look at the health information, the portal also allows people to make organ donor declarations or to assign a representative who can access your health data. This solution is also intended for elderly people who, for whatever reason, can’t use e-services by themselves but need the information to be accessible to a third party.
People can also make their data inaccessible in the health information system, either completely or by one document at a time. Before making this decision, the system will inform the user that making data inaccessible may influence the accessibility of the health data relevant to the patient’s treatment process. This option has not been used very widely – since the start of collecting data in the central health information system in 2008 only 500 people have made this choice. Showing that e-service solutions are considered to be useful and secure by the people of Estonia.
E-health data saves time and money
Healthcare is no longer the only field where e-health data is being used. Patients can give consent to allow the data in the health information system to be used in having a disability attested, to have their capacity for work assessed, or to assess their health before military service. People have also accepted electronic medical certificates, which allow driving licences to be sent by post after passing the necessary health check required – the decision regarding the medical certificate moves electronically from the doctor to the public road administration.
These solutions save valuable time – when a person has gone to the doctor and the data exists digitally, the information can be reused. This helps avoid unnecessary tests and patients no longer have to present paper documents.
Aggregating and reusing health data can also be valuable in health sector management where it is important to analyse the effectiveness of treatments and other necessary indicators to organise treatment financing or ensure that healthcare is accessible. One good example of this is the cancer screening register that collects data about the results of cancer screenings and allows the regular assessment of the effectiveness and quality of screening programmes, as well as conducting epidemiologic research.
The objective of the state is to help patients get the right treatment at the right time via e-health solutions. For this, health data needs to be entered into the health information system in a timely manner so that the information is accessible for doctors when they have to make treatment decisions. At the same time it is important that doctors and nurses have fast and convenient access to health data. This way, doctors do not have to go through every transferred document to find the information they need, which means more time to treat people.
E-health solutions are constantly changing and need to keep pace with today’s innovative solutions, e-health solutions also need to take into account the changes in the treatment process and patients’ wishes.