Estonian e-health

Artur NovekEstonian eHealth Foundation

Implementation manager / Architect

2

Estonia - 45 000 km21.29 mlj. Inhabitants

GDP:Agriculture 2,7%Industry 26,3%Service 74,5%

Estonia

3

E-STATE ARCHITECTURE

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

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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

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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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NATION- WIDEHEALTH INFORMATION EXCHANGE PLATFORM2008 december

PRESCRIPTION CENTRE2010 january

PATIENT PORTAL2009

X-ROAD GATEWAY SERVICE2009

Architecture

06.02.2013 15

SECURITY & AUTHENTICATION

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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

06.02.2013 19

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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PATIENT PORTAL (UPGRADE)

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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

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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

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Patient portalNumber of queries

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Number of queries

2626

06.02.2013 27

LEARNING

POINTS

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• 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“

„App Store“

Speciality based applications

06.02.2013 34

FUTURE

OUTLOOK

35

Thank you!