Alexander Welscher: Diagnosis: e-Healthy
Estonia has revolutionized its medical sector and healthcare system with innovative e-solutions. The small nation is a big leader in e-Health. All the infrastructure was in place before the COVID-19 pandemic – one medical institution has been in operation since medieval times.
It is a must-see for any Tallinn tourist. The Raeapteek on the square beside the medieval Town Hall is considered one of the oldest pharmacies in Europe – and at the same time one of the most modern. It has continuously been in business in the same premises ever since the early 15th century and will celebrate its 600th anniversary this year. Back in the Middle Ages, the pharmacy sold a wide variety of medicine and potions that were concocted by the pharmacist on the spot. Some people came from far away to get their medical items which, back then, included peculiar goods such as black cat's urine, earthworm oil and dried frog's legs. Others undertook long journeys to receive advice and spiritual assistance in Raeapteek.
Nowadays everything runs much faster. Patients only need to insert their personal ID-card into a reader at the counter in the pharmacy to get their medication. This is made possible by the Estonian e-prescription system that immediately shows pharmacists what preparation the doctor has prescribed for the patient and how to dose it. They simply access the patient's information from the system and issue the medicine entered by the doctor electronically with the aid of an online form. Today, 99 percent of all prescriptions in Estonia are issued in this way – around 800,000 per month.
The e-prescription system was launched at the beginning of 2010 and, although the transition from paper to digital hit some minor bumps, the uptake was very fast. Already at the end of the first year, 84 percent of prescriptions were issued digitally. Not least because the system instantly delivered convenience and saved time and effort for all involved. What's more, visits to the doctor are no longer needed for repeat prescriptions. Patients can call up or email their doctor, and the medic can issue routine refills online with just a few clicks – it usually takes a mere 10 to 15 seconds. This has further reduced the administrative strain and brought the need to visit a doctor's clinic to a minimum. Patients do not even have to go to the pharmacy anymore but instead can log in to an e-pharmacy and order their medicine for home delivery for a small fee – a big advantage in COVID-19 times. Other changes and adaptions to the pandemic have proven to be more challenging, even in a country as digital as Estonia.
The pandemic effect: COVID-19 and the Estonian health system
COVID-19 has been challenging the health systems of almost every country in the world. Estonia is no exception, and its e-health infrastructure has proven to be both highly useful, yet unprepared for the crisis at the same time. While the rapid development and launch of new services, such as automatic sick leave letter admission, the track-and-trace app Hoia and a robot for calling patients, helped to contain the spread of virus, the healthcare information systems and databases ultimately lacked functional solutions for handling vaccinations. This even forced a return to paper in e-Estonia: family doctors had to exchange data via printed spreadsheets that needed to be filled out and entered into the computer by hand. "Irony of the digital state" is how a family doctor described the situation in an opinion piece for ERR.
A survey on citizen satisfaction with health and healthcare in Estonia showed that 97 percent of its users are satisfied with e-prescription. Together with the e-tax return, it is the most popular and most frequently used e-service. Estonians are now even able to use their e-prescriptions abroad and access medicine in pharmacies across the Baltic Sea in Finland. Likewise, Finnish patients can also purchase medicine in Estonia with digital prescriptions issued in their home country. This cross-border exchange of e-prescription data has been operational since January 2019. Similar cooperation has also been launched with Croatia and Portugal. Other electronic cross-border health services are still limited in Europe. This is not a problem of technology, but rather of legislation.
Easy, rapid and safe access to medical records
The e-prescription as a centralized paperless system for issuing and handling medical prescriptions forms part of the e-health record system – the Estonian National Health Information System (ENHIS). It is a nationwide umbrella system that connects and integrates data from all medical institutions and health providers, such as hospitals, pharmacies and laboratories, to create a common record. It allows users to share defined medical documents, even though the providers may be using different systems or data formats.
"We have a free market, so every institution can pick any software it wants. But we have created a central health information exchange platform which works like a repository where all the institutions have to send the agreed amount of standardized medical documents. And then other partners can request the necessary data," digital health expert Madis Tiik explains the overall architecture of ENHIS. The family doctor and former CEO of the Estonian e-Health Foundation has been involved in e-Health development projects in Estonia from the very beginning.
There are close to 40 million health documents in the e-Health system that can be exchanged in a matter of minutes and basically contain the entire medical history of the population from birth to death. All the data is accessible online for authorised healthcare providers and patients using their ID-card. It is backed by the X-Road, which allows a secure data exchange between databases in e-Estonia. Every month, more than 2.7 million queries are made in the system by healthcare professionals and more than 2.5 million by patients. The integrity of the sensitive health information is secured by KSI blockchain technology – Keyless Signature Infrastructure.
Behind the scenes: e-Estonia, X-Road and e-ID
Estonia has been building up its e-government and the necessary IT infrastructure since the mid-1990s, not long after regaining independence from the Soviet Union in 1991. Routinely referring to itself as "e-Estonia," the country has been digitalizing almost every aspect of public life and made radical steps to eliminate paper in its interactions with citizens – often in partnerships between state institutions and private companies. Today, 99 percent of public services are available online and can be accessed by using a secure digital ID. Estonians only have to see the inside of public offices to get married or divorced or for real estate deals.
X-Road is the backbone of e-Estonia. Launched in 2001, the nationwide open-source software platform allows the various public and private sector e-service information systems to link up and function together. The X-Road enables them to share, exchange and harmonise the decentrally stored data through end-to-end encrypted pathways for offering services to Estonian citizens. The data is stored where it is created, with each entity administering its data separately. The infrastructure is supported by a "once only" policy, which determines that each citizen's data and other information must be recorded only once and may not be duplicated.
Digital access for citizens to all e-services is provided by an electronic identity card. The legal photo ID-card with a special data chip can be used for identification purposes and enables Estonians to prove their identity online and produce legally binding digital signatures. The ID system is the residents' bridge between the physical and digital worlds, and makes day-to-day activities painless in comparison to other parts of the world. It is secured by a 2048-bit public key encryption.
Patient-oriented system and services
Each person in Estonia who has visited a doctor has a trackable online e-health history. The sole owners of the data are the patients, who have direct access to their own records, as well as those of their underage children and of persons who have authorized them to access their medical data. By logging into the patient portal digilugu.ee with their ID-card, patients can see and review their medical history: past doctor visits including diagnosis and ambulatory epicrisis, current prescriptions, health scans, X-ray results, blood tests and lab reports, as well as their insurance status and medical bills reimbursed by the Estonian Health Insurance Fund.
This information is also visible to their family doctor and other authorized healthcare employees who access the e-health record system in the same way. By locking or unlocking their medical records, patients can manage and control who has access to their data and at what level. This makes it easy to get a second opinion from another doctor or change the healthcare provider – all data can be made accessible without the need to carry any paperwork around. Even more so since multiple telemedicine solutions are available in outpatient care, while doctor-doctor consultations take place online by using digital forms. Yet the adoption had been slow before the COVID-19 outbreak and several lockdowns which led to a widescale uptake.
To find and book a visit to doctors and health specialists, patients can use the national e-booking system which has been developed since 2019. In the self-service environment, patients can choose the date, time and doctor, and be notified ahead of their appointment. This started out as a pilot program at the North Estonia Medical Centre (PERH) with the goal of taking the workload off the medical staff and ensuring a more efficient use of the doctor's time and medical devices. The results were more than convincing, but the roll-out was not as smooth as expected. Doctors were initially worried that they would lose control of their schedule if patients could book appointments by themselves, but soon figured out the advantages of the system, especially in COVID-19-times. It has now been joined by over 100 healthcare institutions in Estonia.
Built-in trust and transparency
No healthcare provider is able to go ahead and check the medical records of patients as they please. All queries are registered by name and all activities are saved in a log. "Patients have full transparency on who has seen their personal information," says Anna Piperal, managing director of the e-Estonia Showroom in Tallinn, adding that this helps patients protect their data. "This is not possible on paper. Never." Going beyond this, the logbook system also mitigates insider threats and ensures that everyone uses the system as they should. "No one would be able to delete your blood type or your allergies or fake records without becoming known."
Violations and privacy invasions are punished severly. Some doctors have even lost their licenses to practice medicine because of unauthorized and illegitimate access to patient data. These serious sanctions prevent misuse. "You do not study for ten years to lose your licence over a few wrong clicks, just to satisfy your curiosity," outspoken e-Estonia advocate Piperal says with conviction.
Estonia's health service has been digital for 13 years now and was rated #1 in the latest Digital Health Index of the Bertelsmann Foundation, with a clear gap to all other countries. The Annual European eHealth Survey, conducted in collaboration by HIMSS (Healthcare Information and Management Systems Society) and McKinsey, also sees Estonia as the leading country for e-health innovation in Europe. One of the main reasons for its pioneering role is that patient engagement, empowerment and trust-building were core components of ENHIS from the beginning. "The key point to e-governance and the healthcare system is confidentiality. This data is among of the most critical, crucial and sensitive in Estonian legislation", emphasizes Piperal.
Another advantage is the strongly connected ecosystem and nationwide partnership between health-related stakeholders in Estonia, who are committed to accelerating the adoption of e-service and digital health solutions – both in their home market and internationally. Many of them want to simplify, improve and speed up everyday life. Ultimately, however, the citizens are the users of digital technologies. They have to understand and be convinced of their added value. "This means that you have to design e-services that are user-friendly and easy to use, so that even the elderly can use them", Piperal says, adding that the e-prescription is a "great example" of such a service because it does not require people to be digitally literate. All they have to do is go to their preferred pharmacy and present their ID card to get their medicine.
Difficulties some patients might only encounter in Raeapteek when they try to get treatment with the ever-popular Klaret – a spiced pharmacy wine created in 1467 in the pharmacy which is supposed to prevent 99 diseases. The distinguished substance is not yet available on prescription – neither digitally nor otherwise. But you can get it during a visit to or a guided tour through the historic premises.
This article appears in the latest edition of the Baltic Business Quarterly magazine published by the German-Baltic Chamber of Commerce in Estonia, Latvia and Lithuania, and is reproduced here by kind permission.
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Editor: Marcus Turovski