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National Health Information System - Follow up

Country: 
Estonia
Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
(15) 2010
Author(s): 
Ain Aaviksoo, Janek Saluse
Health Policy Issues: 
New Technology, System Organisation/ Integration, Quality Improvement, Access, Responsiveness
Reform formerly reported in: 
National Health Information System
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes yes no

Abstract

National health information exchange and reference platform or Estonian Electronic Health Record System finally started in December 2008. Countrywide e-prescription system was launched in January 2010. Integration with both systems was made legally mandatory for all providers and pharmacies, which probably explains the rapid uptake by professionals. However, active secondary usage of discharge summaries is still low and e-prescription project was temporarily suspended due to technical .

Recent developments

The Estonian Electronic Health Record (EHR) System was officially launched on December 17, 2008. The Health Services Organization Act and the Associated Acts Amendment Act accepted by the parliament on December 20, 2007, provided that as of September 1st, 2008 the health care service providers are obliged to forward predetermined medical data to the EHR. However, as the secondary acts (bylaws) were signed by the Minister of Social Affairs only in August 2008 and the technical solution was still in a working condition in December, the operational start of the EHR took place one year later than initially scheduled. The final implementation of full digital interconnectedness of Estonian health care providers is still scheduled to be finished by the end of 2013.

Currently, the agreed amount of data that is sent to the system contains discharge summaries (for inpatient and outpatient episodes), referral letters and references to digital images. The list of data is defined by the Ministry of Social Affairs [1] in accordance with the Government Decree on Estonian Health Information System [2] and the Health Services Organization Act.

The first phase of the Estonian eHealth System was planned to contain four components: Electronic Health Record, Central Digital Image Repository, Digital Booking and Referral System, and Digital Prescription - all mandatory to all providers and available throughout the country.

As the initial take-up of the EHR by providers was relatively low in July 2009 the Government added 20 Million EEK (1.3 million EUR) to the reimbursement prices (out of about 7 billion EEK or 450 Mio EUR total budget) of healthcare services to cover the additional costs of integration with EHR to the providers. This move was taken in response to the demand by providers who complained that the financial incentive to join the system is negative.

The patient portal of EHR was finally opened in September 2009 - nine months later than the first information was transferred to the system by providers. Currently, the patient portal is working according to minimal functionality: it enables to see stored documents and the access log by all users; it also enables to close and disclose one's records.

The Digital Image project has been implemented successfully and according to the plan. The system is actively used and well-accepted by the providers. Other changes to the initial e-health projects are more substantial.

The Digital Booking System is not yet operational as of April 2010. It is also clear that once opened, it will function differently from the original plan due to resistance from the providers. The initial idea was that the Digital Booking and Referral System is the central database and service platform for appointment booking, changing and reminders, plus sending referral letters. The functionality that has been implemented contains the tool for sending and responding to referral letters for providers. For the patients it is foreseen that the system will perform inquiries about the available appointment time them, but not book the appointment in real-time, as the providers will maintain their own local booking systems. The referral letter and respective response system is functioning relatively well (see under "Implementation").

As for the Digital Prescription system it was decided that the project will be developed separately by the Estonian Health Insurance Fund (EHIF) and not by the Estonian e-Health Foundation (EHF). After delayed development and testing it went live in January 2010. Similarly to EHR it was made mandatory to all providers and pharmacies to comply with the system and prescribe and dispense all medication electronically, except for special occasions. Yet, despite the fast take-up of the solution by health care system participants - 75 percent of the prescriptions were prescribed electronically just within three months (see under "Implementation") - the project had to be temporarily suspended due to public pressure by pharmacies, which referred to frequent technical malfunctioning of the system. In April the official statement was released by the EHIF and the Ministry of Social Affairs (MoSA) that until the system is repaired the doctors are encouraged to prescribe on paper if they prefer so. The improved version of the Digital Prescription system is expected to be ready in six months.

[1] Riigi Teataja. Tervise infosüsteemi edastatavate dokumentide andmekoosseisud ning nende säilitamise tingimused ja kord. https://www.riigiteataja.ee/ert/act.jsp?id=13029628 (accessed April 30, 2010)

[2] Riigi Teataja. Tervise infosüsteemi põhimäärus. https://www.riigiteataja.ee/ert/act.jsp?id=13251011 (accessed April 30, 2010)

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Characteristics of this policy

Degree of Innovation traditional neutral innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent system-dependent system-neutral
current current   previous previous

The wonderful starting point, which Estonia had in 2003, when close to 100 percent of infrastructure was already in place, and the years of abundance in 2002-2008 when annual average budget growth for health care was 18 percent, have not been used wisely when it comes to IT use in healthcare. The expectations for coming years are much lower and are very much dependant on smart and decisive political leadership in health care, which has not been the strongest side recently.

The project is now under careful public scrutiny by media, and all stakeholders are using it to fight for their cause. Unfortunately, methods of more efficient engagement and cooperation are not used often enough.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes yes no

Initiators of idea/main actors

  • Government: Very supportive, for Estonia is being branded as quick IT adapter and eGovernment is high on the agenda.
  • Providers: In general, all stakeholder favour the meaningful use of IT in the health care system. Sometimes they oppose the chosen policy measures of implementation, which results in a neutral net result of their position.
  • Payers: EHIF has taken the lead in the Digital Prescription project but is somewhat reluctant and sceptical towards other developments.
  • Patients, Consumers: Estonian people like to be part of an innovative and IT-savvy society, yet recent set-backs with major IT-projects in different areas have made people sceptical. It is important to note that patient representation bodies are relatively weak in Estonia.
  • Media: Media also supports the image of Estonia as the IT leader in the world, but similarly to people they do not favour the poor management of the development projects. As a consequence, the net position therefore is rated as neutral.
  • Others: Formally, the Estonian E-Health Foundation is the leader of national e-health projects but due to its legal nature the foundation is sometimes easily captured by stakeholders.

Stakeholder positions

The Government of Estonia has publicly developed the national e-health system since 2003; the Estonian E-Health Foundation was established in 2005. Official results were planned in 2007, formally promised in 2008 and actually implemented in 2009. Many services (patient portal, e-prescription) were only launched in late 2009 or in 2010, and there are still technical problems which prevent the full use of the services.

All this has made almost all end-user stakeholders wary about the new developments. Additionally, there is growing consensus on the poor financing of IT-solutions that does not cover the risks of inevitable unintended consequences, but is too often compensated with force of the law, which then leaves the responsibility to providers, pharmacists and patients.

On the one hand, most Estonians are sincerely proud to be part of a very IT-savvy society. On the other hand, public services are a sensitive matter and therefore any mistakes or worsening of the current non-digital service provision level is met with relatively strong criticism. For example, two years ago the Chief Information Officer (CIO) and the chancellor of the ministry and later on the Minister of Social Affairs were sacked due to a failed launch of the IT system for pension accounting.

When digital prescription was downgraded from mandatory to secondary option due to technical problems and after fierce opposition from pharmacists, physicians and the media, the Prime Minister took a stand and declared the implementation of the project a disappointment.

During a recent policy seminar on information age in healthcare in Estonia, the general conclusion was that the main strength is the overall understanding of the need and willingness to adopt meaningful IT solutions in health care. Poor financing (only 1 percent of the health care provider turnover) and lack of national level strategic leadership were listed as the two biggest challenges for further development.

All three major players - the Ministy of Social Affairs, the Health Insurance Fund, and the E-Health Foundation - are strong proponents of national e-health developments. The problem is that their priorities differ and therefore common central leadership is missing. Consequently, there is no national strategy defining the priorities of IT development in healthcare in Estonia.

Therefore, the current situation is that the Hospital Association has officially asked to halt all new central developments until the current system is functioning properly. State funding for new public IT developments, which is coordinated by the Ministry of Economic Affairs and Communication, was limited to only one project (out of five planned) for e-health in 2010, due to unclear policy guidance and stronger competing projects from other sectors. The E-Health Foundation is sending out signals that it cannot manage the national projects in the situation of poor financing and low support from stakeholders, including the Ministry of Social Affairs and the Health Insurance Fund. Patients are getting dissatisfied with the unfulfilled promises about an all-digital National Electronic Health Record with many useful services for patients and health care providers.

The EHIF promised that the Digital Prescription project should be fully functional by autumn. Until then no major developments are expected. The general elections are in March 2011 - no high risk changes will be introduced before then.

Actors and positions

Description of actors and their positions
Government
Ministry of Social Affairsvery supportivevery supportive strongly opposed
Ministry of Economic Affairs and Communicationvery supportivevery supportive strongly opposed
Prime Ministervery supportivevery supportive strongly opposed
Providers
Hospitalsvery supportiveneutral strongly opposed
Family Physiciansvery supportivesupportive strongly opposed
Pharmacistsvery supportiveneutral strongly opposed
Payers
Estonian Health Insurance Fundvery supportivesupportive strongly opposed
Patients, Consumers
Individual patientsvery supportiveneutral strongly opposed
Estonian Patient Advocacy Associationvery supportivesupportive strongly opposed
Media
Broadsheetsvery supportiveneutral strongly opposed
Others
Estonian E-Health Foundationvery supportivevery supportive strongly opposed
current current   previous previous

Influences in policy making and legislation

The concept has remained unchanged. However, in the very beginning a dedicated act for the National Health Information System was anticipated. This transformed into a chapter within the existing Health Care Services Organisation Act, which stipulates that the Decree of the Minister of Social Affairs will define mandatory information that all providers have to send to the National Health Record for reference purposes.

Further, e-prescription was finally regulated under the Medicines Act and implemented as a database under auspices of the EHIF. That means, it was developed separately from the rest of the national health information system. While all national level information system components are legally under the control of the Minister of Social Affairs, such separation of responsibilities between independent public agencies makes it difficult to coordinate legal responsibilities and funding.

A third change was related to the reimbursement prices that where increased by the government for all hospital services with a small markup for IT-investments. This was done in response to the demand by service providers as the purchasing system foresees that health care service prices must cover all costs.

A fourth issue was related to the e-booking component of the national health information system. The initial plan was to keep a reference database of all available appointments for outpatient visits accessible via a national patient portal. However, this was changed under the pressure from providers who refused to fix their appointment times well in advance so that they can be handled centrally. Instead, only the estimated waiting time for a specialist is visible via the central system, but electronic booking must be performed using the individual provider information system or via a good old phone call.

Legislative outcome

Hold

Actors and influence

Description of actors and their influence

Government
Ministry of Social Affairsvery strongvery strong none
Ministry of Economic Affairs and Communicationvery strongstrong none
Prime Ministervery strongneutral none
Providers
Hospitalsvery strongvery strong none
Family Physiciansvery strongstrong none
Pharmacistsvery strongstrong none
Payers
Estonian Health Insurance Fundvery strongstrong none
Patients, Consumers
Individual patientsvery strongweak none
Estonian Patient Advocacy Associationvery strongweak none
Media
Broadsheetsvery strongweak none
Others
Estonian E-Health Foundationvery strongstrong none
current current   previous previous
Prime MinisterMinistry of Economic Affairs and Communication, Estonian E-Health FoundationMinistry of Social AffairsEstonian Patient Advocacy AssociationFamily Physicians, Estonian Health Insurance FundIndividual patients, BroadsheetsPharmacistsHospitals

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Initial implementation of the national Electronic Health Record was low after it was made mandatory to all providers in 2009. Although the start of the system was postponed at least a year from the final official plans, the providers and software vendors were not ready to react quickly enough to the demands from the central system. The increase in service prices probably worked as a positive incentive for the providers, even though the increase was relatively small and not specifically targeted to IT investments.

In a recent study it was again confirmed that general willingness to adopt new IT solutions is rather high among Estonian doctors and hospital managers. However, the opinions differ on preferences about the priorities and sequence of implementation.

The negotiations with stakeholders have not been smooth. One of the largest and the only university hospital only started actively participating in the system in 2010. The mandatory use of digital prescription was temporarily halted after pharmacists and doctors complained about the intermittent performance of the central system (see below in section 4.5) and the Estonian Hospital Association has started to lobby for freezing new developments until the existing functionalities are fully working. The failure of the digital prescription project brought about a major public outcry and the Prime Minister has called the project a disappointment.

In the following table the usage of the Electronic Health Record is presented according to the registered data from the Estonian E-Health Foundation [1]. One can see that in 2010 the monthly amount of new documents that was sent to the central system is growing and exceeds the result from the whole year in 2009. Therefore, the collection of documents is actually working. For example, by the end of March 2010 about 300 000 Estonians (22 percent of the population) have at least one reference in the Electronic Health record and over 80 percent of inpatient discharge letters are available in the system.

Document Type

2009

January 2010

February 2010

March 2010

Medical Documents (cumulative)

350 622

572 634

909 035

1 103 981

Inpatient Discharge Letters

63 486

73 065

88 267

131 329

Outpatient Discharge Letters

81 275

98 026

124 135

153 581

Daycare Discharge Letters

1066

1506

2090

2604

Links to digital images

121 748

136 213

155 578

177 637

Referrals

231

238

272

307

Referral's answers

82 827

94 741

110 560

128 916

Birth Discharge Letters

-

-

-

31

ePrescriptions (launched in 01.01.2010)

-

276 965

401 387

509 576*

Dispensed medication information

-

149 990

221 630

193 094

*Note: all of the ePrescription's information was not sent to the central system in March.

[1] Estonian E-Health Foundation. Overview of Estonian Electronic Health Record (EHR) System. April 7, 2010 http://eng.e-tervis.ee/news/overview-2.html (accessed April 30, 2010)

Monitoring and evaluation

The Estonian Health Insurance Fund and the Ministry of Social Affairs traditionally monitor public and service providers' (including pharmacies) opinion once per year in autumn. Specific evaluation for the national health information system development has been not done so far.

The actual figures about the inbound traffic of the national Electronic Health Record were described above (section 4.4). In Estonia the secondary use of health care information has been described as the stumbling-stone for moving from good infrastructure to effective utilisation of the benefits of IT in healthcare (Empirica 2008).

In April 2010, Praxis conducted a study about the use of and attitudes towards IT in hospitals, which included a rapid survey among physicians and managers. Computer use is a must for doctors and managers in hospitals - all administrative and main clinical information is stored in a local medical record, as communication with the Health Insurance Fund is only possible via an online electronic channel since 2004.

Use of electronic sources of information for work purposes among Estonian hospital physicians and administrators

Own hospital Electronic Medial Record

98%

Internet sources

79%

Digital Image Bank

71%

E-prescription

62%

E-mail from ohter health workers

59%

National Electronic Health Record

44%

E-mail from patients

31%

Electronic Medical Records from ohter service providers

31%

Internet social networks

15%

Source: 2010 April, PRAXIS

It can be said that in general all major options for gaining information on professional work are utilised by Estonian doctors and managers. Yet, the survey showed that while the spirit is high, the main problem remains the technical usability and the performance of the solutions.

This has probably prevented major care provision processes to be re-designed for more efficiency or other purposes. Currently, IT remains as an improved tool to obtain missing information, which was also ranked by the respondents as the highest desirable goal for further e-health developments in Estonia.

In 2009, the Estonian E-Health Foundation together with Praxis and the Tallinn University of Technology launched a project for the development of a methodology for estimating the costs and benefits of a nationwide health care information exchange platform (i.e. Electronic Health Record). The preliminary results will be available in autumn 2010.

Currently, the plans for implementing a national Electronic Health Record have remained largely unchanged. The speed has slowed, but new projects are being initiated: e-Ambulance Service, decision support service for providers' EMRs etc.

However, recently poor funding has been recognised as the potential weak point in further developments: currently providers spend on average only 1 percent of their budget on IT, while the suggested level is 2.5-5 percent. Also national budget for health care IT investments is smaller due to exhaustion of the EU structural funds and much poorer opportunities of own national budget.

Expected outcome

The central collection of health data can be considered successful. However, the non-monetary price is apparently high. Most of the changes have been introduced as mandatory requirements through law and end-user investments are left onto them or are minimally compensated after long bargaining. Any new developments are much harder to introduce, especially if the overall poor financial situation in the health system is taken into account.

Downside is that the current IT investment level both at central and end-user side will probably not give any financial gains or create systemic impact on quality or access to services. This makes it even more difficult to justify further investments and negotiate with stakeholders to make their contribution.

Central leadership and decisive prioritising is probably the best and only solution if the positive trend of IT use in health care is anticipated for the whole system in the country, rather than remaining into a few domains of excellence.

The greatest asset is the relatively good attitude of the whole population and health care professionals towards innovation and IT use in health care. At the same time, the manoeuvring room for policy makers and change managers has become much smaller.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low low very high
current current   previous previous

Until now the innovation has all added new services or opportunities for providers and patients - the resistance towards actual change of care processes or financial arrangements have yet to be tested. Yet, only the real change of inefficient or risky practices can deliver the true benefit of IT.

So far, the secondary use of health data remains a problem in Estonia. This is very much dependent on IT solutions and interfaces available at the providers' side and not centrally. At the same time, investments into IT have been traditionally very low in Estonia - one percent of providers' budget. No real difference is to be expected until this proportion is increased up to two percent or preferably three till four percent. Difficult financial projections for the next upcoming years make this change unlikely without clear central support.

References

Sources of Information

  • Estonian E-health Foundation (2010) Overview of Estonian Electronic Health Record (EHR) System http://eng.e-tervis.ee/news/overview-2.html
  • Empirica (2008). Benchmarking ICT use among General Practitioners in Europe - Final Report (http://bit.ly/EmpiricaGPICT2008)
  • A Aaviksoo, J Saluse, G Paat (2010). Kuidas kiirendada Eesti tervishoid infoajastusse? (How to speed Estonian health system into information age? [In Estonian]). Praxis Centre for Policy Studies Policy brief 6/2010. (http://bit.ly/PRAXIS_6-2010)

Reform formerly reported in

National Health Information System
Process Stages: Policy Paper

Author/s and/or contributors to this survey

Ain Aaviksoo, Janek Saluse

Suggested citation for this online article

Ain Aaviksoo, Janek Saluse. "National Health Information System - Follow up". Health Policy Monitor, May 2010. Available at http://www.hpm.org/survey/ee/a15/1