According to one expert, the root of the problem lies in the underfunding of Estonia's critical IT systems. Meanwhile the Ministry of Social Affairs says its main focus at the moment is on improving the social security system's IT.

One member of the public ERR spoke to, Anne (real name known to ERR – ed.), said she wished to book a specialist appointment with a doctor at private clinic Medicum, via the health portal. Anne duly selected a suitable time and clicked on it, but instead of getting a confirmation, she was greeted by an on-screen error message.

Anne said: "I don't remember exactly any more, but I think the page just kept loading, endlessly. The page that shows the booked appointment in any case didn't appear. I tried again and chose another time, because the time-slot I had previously chosen was no longer listed among available times. The same thing happened again — after clicking, the page just kept reloading."

Anne then went to the Medicum website and, after logging in there, discovered that the original time she had selected had indeed been booked for her in their system.

Yet "that time still doesn't appear in the appointments section of the patient portal," Anne added.

Several other people have shared with ERR in recent weeks similar issues they have had with the health portal. While the first errors appeared as early as the start of January, the Health and Welfare Information Systems Center (TEHIK) has not been able to resolve the appointment-booking issues in the intervening months.

TEHIK director Margus Arm said: "We have actively been searching for a solution to the issue over the past couple of months. Unfortunately, there is no ideal solution which would resolve all the problems. In the meantime, we have changed the frequency of queries and communicated with development partners of various healthcare service providers, so that specialist appointment queries between their and our information systems could be answered more quickly."

"We have also worked on ensuring that times booked elsewhere can be removed as quickly as possible," Arm added.

Arm conceded that there is no perfect solution, adding that TEHIK continues to search for one together with its own development partners, the Health Insurance Fund (Haigekassa), and the development partners of healthcare service providers.

"Of course, we're trying to improve the system, but where we'll end up — we don't know that yet," he added.

When asked who should be held responsible for the issues, Arm said the client is the Health Insurance Fund.

"A centralized development of health-sector information systems is especially complex because any change made in the core may lead to a need for updates in all other partners' systems. This must be done very cautiously — what it could be and whether it's ultimately economically viable. To my knowledge, those discussions are ongoing at the moment — about what the solution might be and how broadly it should be implemented," Arm continued.

He declined to say when the system might be fixed, however, saying "I won't make any empty promises right now."

Anett Pärs, the Health Insurance Fund's digital registry project manager, also conceded that several significant changes have been made to the health portal since the start of the year, in order to fix the error message issue, but she, too, could not say when the service would start functioning flawlessly.

"The system's reliability is improving step by step," Pärs said. "And although the incidence of issues cannot yet be completely ruled out, the volume of error messages has significantly fallen since the beginning of the year."
Pärs said the causes of error messages vary: There are several different types, but not all of them can be resolved solely from the digital registry side.

"Sometimes the system needs to be developed on both the digital registry side and the institutions' side. Since institutions use many different information systems and their technical readiness varies, we still can't say when we'll reach a point where these error messages stop completely, but we are moving in that direction — and quite actively," said Pärs.

Asked whether TEHIK and the Health Insurance Fund were unaware, when creating the new health portal, that some healthcare institutions might not be technically capable of matching the level of the central portal, Pärs said this had always been known.

"That's what we're working toward, and there have been discussions about whether the institutions' systems could be consolidated. We're doing our best to offer a central solution in this situation, because it wouldn't be a good solution if the patient had to browse for appointments through multiple institutions' digital registries. Maybe it actually makes sense to maintain this central system, improve it as much as possible, and perhaps we'll have hope that in the future it will work the way we want it to," said Pärs.

Expert: State information systems are underfunded

IT expert Linnar Viik told ERR that the malfunctions seen in the health portal mainly cause public inconvenience and time wasting.

"The underlying issue here is that family doctor centers and hospitals use different information systems, and integrating them into a single health portal, a patient-centered environment, is complex because various systems must be joined together. These malfunctions cause inconvenience to the individual and wasted time for society as a whole," Viik said.

Viik concurred that the developers of the central system should have considered more that various healthcare institutions' IT systems might not be easily compatible.

"It's the same with this system as with many others. What we're seeing now is chronic and long-term underfunding of sectoral information systems, which has led developers to try to get things working with whatever tools are at hand, and there has not been budgeting in a way that would allow for thorough planning of such consolidation," Viik said.

The Ministry of Social Affairs is responsible for the funding of digital solutions related to health, Viik added.

"Estonia has decided — and I think this is very right — that each sectoral information system is the responsibility of its respective ministry. The role of the digital ministry is coordination; it cannot step in and manage systems within other ministries' areas of governance. Although there have been instances when help has been provided — for example, during the transition to digital prescriptions when the system failed to launch, the State Information and Communication Technology Center (RIT) stepped in. But these are rather isolated cases," Viik noted.

Every government minister must also act as their own fields' digital minister in effect, he added.

"Each ministry's secretary general and the head of each institution must be capable of developing and managing their agency's information systems. To do so, they must also be capable of budgeting. Office spaces are planned, employee salaries are planned — the same should apply to information systems within each institution," Viik said.

The problems with the health portal will ultimately not be resolved, Viik said, until its issues infuriate a minister, noting that members of the public getting irate is not sufficient to prompt change – a minister must be antagonized by the glitches too.

Funding is also a key issue, he said.

"While Estonia has a tight state budget, it is up to the minister to decide where to make cuts or where to find the funding. That many information systems have been developed using EU funds does not mean that European money will always be available — so institutions have to write that funding into their own budgets," he continued.

Minister: Our IT priority is SKA

One relevant minister who did speak about the issue was Minister of Social Affairs Karmen Joller (Reform), who agreed that the healthcare administration's IT systems require constant maintenance and development, but said the ministry currently has triaged systems other than the health portal, ahead of it.

One of these is the Social Insurance Board (SKA) IT system.

"The health portal is being worked on, but within the Ministry of Social Affairs' area of responsibility, the current priority is still the pension and benefits payment system, where there have been significant shortcomings for quite some time. So when it comes to funding needs, SKA's systems come first," she added.

Jaanika Merilo, the Ministry of Social Affairs' e-health strategy lead, said that the synchronization of available appointment times within the health portal has been increased from once every 15 minutes to every five minutes, plus checks are now carried out every minute on whether a time slot has already been booked via another system.

These could be made even more frequent, but only with the accompanying cost, she added. "An even more frequent synchronization would already require significant investments in both TEHIK and the healthcare service information systems."

At the same time, Merilo pledged that the family doctors' system should be back in working order — following thorough testing and the required improvements — by early June at the latest.

Estonia's national IT systems have long been hailed globally as a model example of how an e-state and e-governance should be run, and how citizens should interact with the state.

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