EHR central system advantages and disadvantages, the case of Estonia. Estonian E-health Foundation Raul Mill

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1 EHR central system advantages and disadvantages, the case of Estonia Estonian E-health Foundation Raul Mill

2 Estonia km mlj. inhabitants GDP: Agriculture 2,7% Industry 26,3% Service 74,5%

3

4 HEALTHCARE IN ESTONIA 35 main hospitals 491 family doctors (juridical persons) Healthcare expenditures - 5.9% from GDP % from GDP 2012

5 E-STATE ARCHITECTURE

6

7 SECURITY & AUTHENTICATION

8 HIE platform history Planning initiated Project preparation ( ) ehealth Foundation established (2005) ehealth Projects ( ) National HIE Funding decision by Ministry of Economic Affairs Electronic Health Record Digital Images Digital Prescription Digital Registration

9 Organization Ministry of Social Affairs Society of Family Doctors Tartu University Clinic East Tallinn Central Hospital Union of Estonian Medical Emergency North Estonian Regional Hospital Estonian Hospital Assosiation Standards management Services management Estonian e-health Foundation Board Management board ENHIS Operation Medical Advisory Board IT management Communication management

10 STATE AGENCY OF MEDICINES - Coding Centre - Handlers of medicines HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists POPULATION REGISTER BUSINESS REGISTER HOSPITALS 2009 FAMILY DOCTORS 2009 PHARMACIS 2010 january SCHOOL NURSES 2010 september EMERGENCY MEDICAL SERVICE 2011 E-health architecture X-Road, ID-card, State IS Service Register PATIENT PORTAL 2009 X-ROAD GATEWAY SERVICE 2009 PHARMACIES AND FAMILY DOCTORS 2009 NATION- WIDE HEALTH INFORMATION EXCHANGE PLATFORM 2008 december PRESCRIPTION CENTRE 2010 january 1

11 35 hospitals 491 family doctors 8 main softwares (totally 20)

12 The main security principles of Estonian ehealth system Opt Out 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. Encrypted database that allows to remove the confidentiality risk from the technical administrators 5. Monitoring of all actions together with the corresponding countermeasures (both organizational and technical)

13 Standards

14 Standardization process Specialty assotiations Healthcare providers Social ministry Terminology experts UML+HL7 experts EeHF standardization specialists HIS developers Health Insurance Fund Create data set Data set document UML model Classificators OID-s Formalize and merge Stylesheets XML schemas Description documents Examples Approve and publish Changes in NHIS documents regulatory act Fixed version of artifacts in publishing centre

15 The structure of Estonian Health Information System Institutional level users cooperation model Data Exchange level different e-services Central System Database and related services Healthcare processes User needs Training programs Partnership Communication User software User interface Data input Data Visualisation Searching information Data transmission standards (HL7) Set of data Data Standards Search criterias Legal Framework Software Hardware

16 EHR services for physician econsultation services EHR services for patient Services for Social Insurance Fund Services for dentaal care - Completed - Development Digital registration services Supporting services Services for blood center - Planning Digital archiving services Cross Border Data Exchange services Infrastructure services External services Services for registers Services for nurse eambulance services Subservices Services for homecare Digital laboratory services Health information services for patient Main services of the e-health in Estonia A medical certificate services Data and statistics services Analytics services for participants in treatment process E-learning services for medical staff

17 PATIENT PORTAL (UPGRADE) 1.2 mio persons medical data

18 Acceptance eprescription covers 94% of issued prescriptions. Over 90% of Hospital discharge letters digital Over 97% of stationary case summaries have sent to the central DB Ambulatory case summaries sending No certain rules for sending ambulatory case summaries! 1.2 mio person have documents in central system (92% of population) 92% of family doctors are sending documents to the central system All bigger hospitals use central system on a regular base The central system has over 8700 medical users

19 jaan.10 veebr.10 märts.10 apr.10 mai.10 juuni.10 juuli.10 aug.10 sept.10 okt.10 nov.10 dets.10 jaan.11 veebr.11 märts.11 apr.11 mai.11 juuni.11 juuli.11 aug.11 sept.11 okt.11 nov.11 dec.11 jan.12 feb.12 mar.12 apr.12 may.12 eprescription (94%) ISSUED SOLD

20 March May July September November January March May July September November January March May July September November January March May July September November January March May July September November Retrieval of Medical Documents by Healthcare Professionals

21 Patient portal Number of queries

22

23 LEARNING POINTS

24 Healthcare is a reactive, rather than proactive industry. Solve one specific problem in healthcare, not ten of them. In healthcare you need to have a business model from the start. Healthcare is very interdependent: you have the doctor, the pharmacy, the patient, the insurance provider, and a dozen other stakeholders that any one service has to coordinate with.

25 Comperhensive planning processes and standards, legislation. Usability fast and simple solutions Implementation central training programs Service update continuous feedback Balance between security and usability PIN for every document PIN or ID-card?

26 90000 Medical document sent to Health Information System by General Practitioners

27 FUTURE OUTLOOK

28 Hardware independent Location independent Single sign on Apps for medical specialties Data and services integration Collecting information UI standards Graphical solutions Interoperability

29 Thank you!

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