An Electronic Health Record for every citizen: a global first

Transcription

1 An Electronic Health Record for every citizen: a global first Estonia SYNTHESIS In 2005, the Estonian Ministry of Social Affairs launched a new e-health concept by phasing in four projects: Electronic Health Record, Digital images, Digital Registration and Digital Prescription. The implementation of these projects aims to create a unified national health information system, linked with other public information systems and registers. The core project is the Electronic Health Record (hereafter - EHR), which provides the basic integrated information technology system for all e-health solutions. By the end of 2008, the outcome of the EHR project will be a comprehensive central register and data-exchange of health information from birth to death for all 1.35 million Estonian residents. This will be unique worldwide. In terms of information technology applications, the Estonian health care sector is regionally and institutionally uneven, and lags far behind progress achieved by other public services, such as state registers, taxation, e-voting etc. By 2005, most of the approximately 1200 health care services providers were already deploying an information system or using solutions developed by other providers (e.g. the health care image database created by the Tartu University Hospital, e-services of the Estonian Health Insurance Fund, "Health Bank" of family doctors, etc.). At the same time, the information systems implemented by different health care providers are not mutually compatible and impede mutual information exchange. From the point of view of patients and medical professionals, the existing system of paper-based data exchange is very time-consuming and subject to problems arising from accidental destruction or loss of documents. To address this situation and extend public e-services into the national health care sector, the Ministry of Social Affairs drafted in a strategic framework for the Estonian health care sector information system. This strategy is based on several financial and technical feasibility studies of the national health care system which highlighted a significant potential for more cost-effective services through digital 'at a distance' diagnosis and consultations of doctors and other medical services (irrespective of the location of patients or medical professionals). A targeted and efficient use of IT is essential in order to meet the increasing demands of Estonian society for a quality health service. Other socio-economic objectives of the EHR are to provide accurate medical statistics and a cost-effective governance of national health care. Thus, the EHR is not just a large IT project, it is a social development project involving a large partnership. Alongside implementation of new information technology concepts, it also includes other aspects, such as medical standardisation, ethics and legislation. To ensure effective management of the e-health project, a special implementation agency, the E-Health Foundation 1, was established in This agency is responsible for all 1

2 aspects of the national health information system, and maintains the relevant databases and data exchange systems. The nerve centre of the e-health information system is a centrally managed electronic health record (EHR). This is a centralised medical database available on a restricted access basis to various partners: medical personnel, patients and health care authorities. It is designed to store the most important personal health data, medical records, etc. of the patient from birth to death. EHR stocks information which is urgently needed for the treatment of the patient, as well as information required for national and medical statistics. In addition, it enables searching for additional information from other dispersed segments of the e-health information system (hospital information systems, central system of family physicians, etc.). In terms of IT-architecture, the new system will be an integrated data-exchange system based upon the already operational nationwide IT-platform called X-Road 2. During the pilot phase, EHR performance was first assessed in three of the largest hospitals of Estonia and other pilot partners joined the testing phase: Tartu Ambulance service, the family physician centres in Koeru and Järveotsa, and the State register of Causes of Death. The piloting of the EHR integrated system started in mid and will continue until May The project has already led to 15 followup initiatives and projects (e.g. e-ambulance) aimed at fully deploying the results of EHR in the period From a public policy perspective, EHR is a demanding project since the key success factors of the project are not technical or system innovations but professional consensus and public acceptance of the new form of medical data storage and exchange. The establishment of the EHR Council in 2007 should enable, with the proactive public information campaign, more efficient preliminary consultation and coordination of the project s stakeholders views especially on patients rights and responsibilities of medical professionals and other persons involved in the process of collecting, exchange and storage of private medical data. Background information Country: Estonia Project title: Electronic Health Record Key words: health; information society: services and applications for citizens, ICT access, e-inclusion Duration of project: 1 December December 2007 Funding: total budget 1,594,941 ERDF contribution 1,196,206 national budget 398,735 ERDF Objective: Objective

3 1. PROJECT DESCRIPTION The overall objective of the EHR project is the integration and modernisation of the IT infrastructure of the Estonian national health system. The purpose of the project is to create and upgrade the content and accessibility of basic public services in Estonia and to elaborate several new e-health services. As a result, medical services delivered to patients will be more competent and effective since doctors will be able to obtain operational information about the patient s medical condition. For their part, patients can obtain a comprehensive overview of the use of their personal medical information by medical establishments, state authorities and other participants in the EHR project. The project is extremely important for national health care governance, as the EHR will deliver public health-care services more effectively, and will provide accurate and updated medical statistics enabling better and more efficient health care planning, organisation and financing. EHR is a complex multi-annual project involving a number of partners. The following inter-linked activities have been identified: creation of an adequate legislative framework and wide discussion of medical ethic issues in advance of implementation of new public services. The objectives and means of EHR should be accepted by society; creation of an organisational infrastructure to manage the project and to operate EHR in the future; development of information technology (IT) processes and services, together with implementation of quality management in partner organisations are essential activities of EHR; since the EHR project will establish new digital services, elaboration of datamodels, description, standardisation and classification of medical data will be necessary; linked with the foregoing, a system architecture, data exchange and access requirements need to be elaborated and relevant software programmed; activities enabling implementation of IT infrastructure (equipment procurement and installation, integration of users, set up of databases, etc.); due to the novelty and technical complexity of EHR, ongoing training of users (medical staff, pharmacists etc) and informing the partnership and society is a major part of the project action plan. The coordination of these activities is the responsibility of the E-Health Foundation (EHF) 3, an independent organisation established in 2005 by the Ministry of Social Affairs of Estonia and several other healthcare institutions. Implementation partners for all activities are the IT-companies selected by means of public procurement procedures. The partners and beneficiaries of the information system are medical establishments or other legally entitled persons who have entered into a contract with the E-Health Foundation and have the right to use EHR data and exchange medical information through the EHR system. The partners and direct beneficiaries of the 3 3

4 health care information system are all institutions and persons directly related to the provision of health care services. They include family physicians, clinics and hospitals, ambulance, pharmacies, health care employees of other public sector establishments (e.g. school nurses and doctors, medical personnel of prisons, etc.), compilers and users of medical statistics, providers of medical and health tests, health care registers, Central Health Insurance Fund, and patients. National health care institutions are the first and most direct beneficiaries of the implementation of the Electronic Health information system, of since the data collected and stored by EHR significantly supplements the information on the basis of which the 8 billion EEK (approximately 0.51b) national health care budget is allocated annually. By the autumn of 2007, the main results of the project were the establishment of an organisational structure for e-health (E-Health Foundation), and the elaboration of an adequate legal basis (The Health Information System Draft Act, 2007); data models, classificatory standards and descriptions will be incorporated by law at the end of All the results mentioned here are subjects of continuous development and improvement. To facilitate this process, the virtual Publication Centre of Classificators has been established under EHF 4. Most of the required IT equipment and software has been procured and installed, and IT solutions and system integration are ready for piloting; a full integration timeschedule has been prepared by the suppliers consortium. A completely new public service tool, the Patient s Portal, is being developed under the project. This enables a patient to access his/her medical data irrespective of time and place. Patients can monitor the data that has been collected about them and can consult their personal medical records. They can also determine by whom, when and why their EHR data has been accessed. Patients can also prohibit access to personal medical data or add remarks to the EHR data (for instance, allow or plan blood transfusions or organ donations). With the therapist s agreement, it is possible to forward messages about a patient s health condition (i.e., blood pressure records, etc.) via the portal. Access to the portal will be possible by means of electronic ID-card authentication. Administratively and financially, the EHR project should have a positive impact on costs and activities by reducing paperwork, and improving the archiving system. EHR will provide better and less time-consuming medical services for patients. Patients have indicated that the existing system is very time-consuming (e.g. they have to visit various doctors all of whom hold their medical information on paper.) EHR will improve and accelerate the exchange of information between different doctors and medical institutions (mutual consultations, exchange of experience and consideration of the second opinion of different specialists). All patient or treatment-related information will be effectively documented, and EHR could enable exchange of information not only within Estonia, but also with national healthcare system in other 4 4

5 countries. It will also be important in cases of emergency by providing urgently required information about a patient s condition. The overall objective of the EHR project is not only modernisation of the national system, but also alignment with the e-health policies of the EU. Learning from 15- years experience of e-health implementation in other member states, EHR will contribute to EU-wide initiatives like "e-health - making healthcare better for European citizens: An action plan for a European e-health Area" (EU Commission Communication, 2004), as well as to the EU Member States common declaration on their commitment to pursue structured cooperation on Europe-wide cross-border electronic health services. European Regional Development Fund (ERDF) support created favourable conditions for the introduction and implementation of modern e-health principles and technical solutions in Estonia. The ERDF contribution made possible the simultaneous start-up of all the complex activities, and the encouragement of participation by multinational IT-companies in service and equipment procurements. It was therefore possible to attract new service standards, and special technical and implementation expertise not previously available in Estonia. 2. POLITICAL AND STRATEGIC CONTEXT The Estonian health care system is based on the solidarity principle. All public health services are covered by the compulsory national health insurance, which is funded by social tax contributions payable on all wage earnings; 13% of which is paid into the Health Insurance Fund (Haigekassa). In addition to taxpayers, the Health Insurance Fund cover extends to pensioners, pregnant women, children under the age of 18, unemployed and disabled persons. Virtually all (in 2005, 94.5%) of the 1.35 million Estonian population, and 90% of all health care services are covered by the Health Insurance Fund. As a result, public expenditure on health care is relatively high and the Government faces continuous pressure to increase it. At the same time, patients expect prompt access to medical services without any deterioration in quality of service. Evidently, optimisation and cost-effective management of health care services represents an important dynamic towards the implementation of a set of new e-services. In the past, the strategic planning capacity of Estonian public authorities and political institutions has been hindered by the absence of a reliable and integrated means of collecting and collating medical data. Planning of new medical establishments, national vaccination programmes or the procurement of medical equipment all suffered as a result. Another factor encouraging data integration is the need to prevent the overlapping of activities and the storing of patient information in several medical institutions exclusively for in-house use. According to the Estonian Health Board registers, in May 2007, there were 63 licensed clinics and hospitals, 17,666 medical employees (including 5,335 doctors and 796 general practitioners), over 160 different medical services and 1,043 service providers. In-house electronic patient records are used in 5

6 nearly all of these organisations. Before the EHR project, no integration existed between different systems, or a systematic digital medical data exchange in the medical community. The general preconditions for the start of the nationwide integration of the health care information system were excellent: during the last decade, Estonia became well known as a country with advanced e-services, not only in the business sector (especially banking), but also in e-government services (e-taxation, state commercial, car and shipping registers, e-voting etc.). The state has already established and maintains a nationwide technical infrastructure called the X-road platform. X-road is a platformindependent standard interface for secure data processing, connection of all Estonian public sector databases and information exchange. Other IT-solutions such as digital signatures and ID-card authentication, are recent innovations, and their use is comprehensively regulated by national law. The EHR concept derives from several strategy plans and policy papers initiated by national healthcare institutions and government bodies - mainly by the Ministry of Social Affairs, under the impact of the European Union e-health related policydocuments (EU Commission Communication "e-health - making healthcare better for European citizens: An action plan for a European e-health Area 1 ) as well as to the EU Member States common declaration 2 on their commitment to pursue structured cooperation on Europe-wide cross-border electronic health services. To ensure patients and medical staff that all personal data will be stored and managed properly and safely, the required legal framework was created. The Personal Data Protection Act of 2003 regulates the basic principles of personal data protection in Estonia. Patient rights within the context of the doctor-patient relationship are governed by the Law of Obligations Act, which came into force in July It is expected that the Health Information System Act will further regulate the issue of patient rights and data protection, and that it will also regulate the technical requirements of the national health information system (data standards, etc.). 1 Commission of the European Communities, Brussels, COM (2004) 356 final 2 ehealth in Europe: Succeeding Together - EU Member States and the European Commission declared their intention to take steps towards implementing a roadmap for cross-border ehealth services at the ehealth conference held on April 2007 in Berlin. 6

7 3. IMPLEMENTATION 3.1. Project design and planning Since the early 2000s, the ehealth vision in Estonia 3 has been constructed on three pillars: the establishment of a nationwide integrated electronic health record system, a strong focus on standardisation and, in particular, on interoperability, and the integration of the existing IT infrastructure using the basic nationwide ITcommunication platforms. Based on this strategic approach, the Estonian Informatics Centre and MSA commissioned a number of studies to find optimal solutions for implementation, such as: 2003, "Healthcare information system concept and elaboration of integration requirements" (commissioned by the Estonian Informatics Centre and carried out by the PRAXIS Foundation and Aprote Ltd) "Health record. Initial study" (commissioned by the Ministry of Social Affairs, and carried out by Aprote Ltd). As a result of these research papers, in 2004 the Ministry issued the "Conceptual vision document of EHR" setting the strategic aims of the project. At its request, Ernst and Young carried out a comprehensive risk analysis of EHR implementation in This analysis identified and assessed four categories of possible risks deriving from: technology, organisational management, public opinion and procurement partners of EHR. To minimise possible implementation risks and assure the sustainability of the EHR project s results, the following functional preconditions were established: i. EHR should be capable of interfacing with X-tee and forward/receipt of standard (harmonised) Electronic Health Records; secondly, ii. To assure personal data protection and patient rights according to the laws, and the legitimacy of data utilisation by medical personnel and authorities, users of EHR must be registered in public registers (register of Health Care Board, Central Health Insurance Fund lists of family physicians, etc.). Before full implementation, the reliability of EHR was tested in some of the largest hospitals. In the pilot phase, Tartu University Hospital, North Estonia Regional Hospital and East Tallinn Central Hospital were chosen, and later other partners joined the testing phase (Tartu Ambulance, the family physician centres in Koeru and Järveotsa, and the State Register of Causes of Death). The piloting of the EHR integrated system began in the middle of 2007, and will continue until May The system is expected to be fully operational by the end of The first document comprehensively presenting the issue of optimisation and modernisation of national healthcare system and structure, was "Estonian Health Care master plan 2015" followed by the strategy paper "Development Plan for healthcare information system " compiled and developed by the Ministry of Social Affairs in The document created the vision for future development of the national e-health programmes. 7

8 3.2. Management, monitoring and evaluation system The EHR project is complex and includes technical, organisational, legal and public relation issues, which require effective strategic and operational management. The highest-level management body is the project management board, comprising representatives of the Estonian Informatics Centre (the state agency for public information and telecommunication services), the Ministry of Social Affairs, the Ministry of Economic Affairs and Communications, the EHF and the suppliers consortium. The Secretary General of the Ministry of Social Affairs chairs the board, which meets monthly. The board is responsible for setting the rules for EHR administration, general performance and finance monitoring, risk assessment and development of the legislative framework. The Ministry of Social Affairs has also appointed a project coordinator from the department of e-health to facilitate external cooperation with the partners and monitor the project s operational performance. Operational management and administration of the project is the responsibility of the Estonian E-Health Foundation. The foundation carries out development, implementation and running of the national health information system on an everyday basis. Its main task is to develop, implement and check the system architecture and working processes of the health information system. The EHR project management team within the foundation consists of a project manager, a technical coordinator (IT-system coordinator) and an assistant. The project management team and the coordinator from the Ministry of Social Affairs work closely together on the key issues of the project: raising awareness and wider involvement of the medical community, IT and service procurement, etc. The E- Health Foundation evaluates suppliers performances and submits regular progress reports to the Ministry of Social Affairs and to the project board. Integration of both management levels is most evident in measures to raise the awareness of society of the social, medical and legal impacts. The Ministry of Social Affairs and the E-Health Foundation have co- organised several round-tables on patients rights, data protection issues, presentations and workshops on EHR technical solutions and message standards. The ministry supports the public relations plan elaborated by the E-Health Foundation and there is systematic communication via traditional and digital media. To inform external and internal partners of project developments and make available new technical regulations, the foundation website publishes progress reports of its work (including legislative, IT-related and standardisation work and positions developed in cooperation with the partners) Governance: partnership and leadership The ERDF Management Authority for the projects under the Development of Information Society measure is the Ministry of Economic Affairs and Communications of Estonia and the implementation agency is the Estonian Informatics Centre. This state agency is also responsible for development and maintenance of the national information technology infrastructure (X-road), which is the core infrastructure element of the EHR. 8

9 To interact more effectively with social and health care sector partners and consult with shareholders on e-health policies, the Ministry of Social Affairs has established an expert body, the EHR Council. The EHR Council has 28 permanent members covering not only beneficiaries, but also the stakeholders of the project: professional medical associations, the Estonian Data Protection Inspectorate, the Estonian Science Academy, patients associations, etc. According to the EHR Council's statutes, the Ministry of Social Affairs relies on the expert opinion of the council in implementation and development of the EHR. The EHR Council meets monthly, and submits its proposals or opinions by means of meeting protocols. The establishment of the council is clearly a positive initiative. The Ministry of Social Affairs now has a systematic opportunity to discuss and set policy measures based on consensus; it is also possible to have an open debate in the council on stakeholders concerns about public awareness, technical (interoperability of in-house systems) or legal issues (e.g. patients rights and medical ethics). External partners provide technical and IT concepts of the EHR system, which is why the project team also includes a technical coordinator. The IT-partners act as a consortium (the lead partner is Hewlett- Packard Estonia Ltd) and all IT-related activities are continuously supervised by the IT-coordinator of the E-Health Foundation. The technical solutions and equipment of EHR will be supplied by Hewlett-Packard Estonia Ltd, a technology company which has previously developed local or in-house health sector information system solutions in the UK, Spain, Austria, Ireland and Lithuania. The other two partners in the consortium, which won the public tender for development of the IT solution, are Microlink Eesti Ltd., and IceFire Ltd (both Estonian companies). Software solutions will be developed by Medisoft Ltd - a company focused on the development and integration of information systems, design of computer software, deployment, consulting, training and sale, modification and maintenance of applications and hardware Innovative elements and novel approaches to implementation In terms of the system architecture, EHR is a complex information technology and communication innovation. The main novel principles of the system are its serviceoriented structure, standard communication method with external information systems via a common message centre, autonomy of services, and its scaleability. Implementation of these principles is important, not only for the technical performance and security of EHR, but also for simplified handling of the system by the end-users, authorised medical personnel or patients. None of these principles is innovative in itself, but their combination in EHR is unique. To comply with the highest management service standards of an information system, the EHR has been developed in accordance with the IT Infrastructure Library 4 series of documents, which is the most advanced management service framework for complex ITsolutions. 4 ITIL is a customisable framework, which defines how IT service management is applied within an organisation. It is also aligned with the international standard, ISO Although ITIL was originally created by the CCTA, a UK Government agency, it is now being adopted and used across the world as the de facto standard for best practice in the provision of IT Service. Although the ITIL covers a number of areas, its main focus is on IT Service Management. (see 9

10 The EHR central database includes three types of data: 1) patient s primary information (including contact details, insurance information, allergies, and important drug information); 2) a link directory of other sources which include stored medical data about patients, for example in the IT systems of hospitals and family doctors; 3) centrally stored medical records (vaccinations, cancer register, etc.). The EHR exchanges all types of medical documents approved by Estonian law. The national message exchange standards are established on the basis of the international XMLbased standard HL7 v3. 5 The requirements of user authorisation and data protection are very important, as EHR handles sensitive personal data. Electronic Health Record is using the most advanced solutions of the X-road platform s two-phased external authorisation system. EHR authorises users of the interfaced medical institutions information systems following their authorisation on the basis of public registers information (users must be listed on public registers). This means, that the EHR administrator will not unilaterally issue rights for end users - for instance, a family doctor will be given user rights, only if that doctor is listed in the family doctors register, maintained by the state authority, the Health Care Board. In-house authentication of EHR users in a medical institution also has at least two levels of protection: authentication via the innovative electronic ID-card infrastructure 6 and log- in rights of the medical institution information system. To assure timely implementation of new technical solutions EHF has a training plan for pilot organisations (recent seminars were held in summer 2007 in Tartu University Hospital and East Tallinn Central Hospital), and further training plans for all institutional partners Key implementation obstacles and problem-solving practices Implementation of EHR started in The extended partnership and rather bureaucratic procedures of the project management caused some rigidity during the initial phases, but collaboration is now established and working efficiently. Progress is well documented and available on the E-Health Foundation website to partners and all interested persons. The multi-level managing and monitoring system does demand time-consuming coordination and reporting processes. For instance, some of the external partners or monitoring authorities only accept paper-versions of documents, and do not use digital signatures or other advanced means of identification. As a result, a lot of papers continues to circulate among approximately local and foreign organisations. Internally, the establishment of the EHR Council in 2007 enabled more efficient 5 Additional information on the international standard HL7 is available on the website 6 ID card infrastructure certification authority is SK (Certification Centre, legal name AS Sertifitseerimiskeskus), which is Estonia's primary and currently only certification authority providing certificates for authentication and digital signing of Estonian ID Cards. ID-card authentication standard has a security level which is compatible with the most advanced electronic banking systems and the respective authentication infrastructure can be used for many e-services (not only for persons identification). 10

11 preliminary consultation, coordination of the local shareholders views and more rapid implementation of decisions. A more complicated external obstacle is the steadily increasing cost of IT-equipment and related services. Some contracts were signed some time ago without fixing exact delivery costs, and at the moment of procurement, prices were higher due to inflation and the global market situation. This situation has been solved with good will through bilateral negotiations between the E-Health Foundation and the suppliers consortium; to avoid similar problems in future it has been recommended that prices of equipment and services should be fixed in the earliest possible phase of contract negotiations. The Ministry of Social Affairs foresaw that public and professional awareness of EHR objectives would be crucial to successful implementation. To inform society and medical professionals, a public relations plan was launched, and respective awareness raising events promoted by E-Health Foundation. In 2007, visibility and awareness of EHR is very satisfactory. A Faktum & Ariko poll in January 2007 (poll sample of 100 family doctors, 100 pharmacists, 32 cardiologists, 25 psychiatrists, 18 neurologists and 9 endocrinologists throughout Estonia) showed that 67% of doctors and 84% of pharmacists support the implementation of EHR, and 90% of doctors and 63% of pharmacists are aware of EHR. The E-Health Foundation website is a well-structured, channel of communication. It not only provides general information but also publishes documents of procurements, partnership meetings etc. The trial version of the E-Health portal ( is designed to provide information about all national E-Health projects. Patient organisations and public opinion have been actively involved in the discussion of patient rights and medical ethics (several round-tables and meetings between 2005 and 2007, documented on EHF and MSA web-sites). In accordance with draft Law, data provided in EHR can only be used by clearly defined persons and organisations for treatment of patients, checking patients medical conditions, the assessment of medical quality and for national health statistics. 4. INNOVATION RESULTS The Estonian concept of implementing the national information system of public healthcare is organisationally innovative because, for the first time it covers the entire country, all medical service providers and related sectors (pharmacy, laboratories, etc.), and all public authorities and institutions. The EU Commission report ehealth priorities and strategies in European countries (Report by ehealth ERA, 2007), highlights the fact that such a system of medical information which registers the health data of every citizen from birth to death is without international precedent. The realisation of the EHR project requires not just implementation of advanced information technology across a deeply complex system. It is widely recognised that significant efforts will be required to organise new service delivery structures and effective management of the new system. 11

12 The specially established new agency (E-Health Foundation) has proven itself to be an effective means of concentrating management, development and technical maintenance of the national health care information system in one organisation. The foundation s organisational structure and in-house competences support further development of e-health services; there is strong project management, analytical skills and technical competences. To ensure the continuous improvement of the services, technical skills are supported by the quality management system (the quality management system complies with ISO 9000 standard series). The most innovative technological aspect is that implementation of the new EHR concept does not cause massive re-engineering of the existing in-house information systems and communication infrastructure, which will just be integrated ( linked ) by special system modules. The message exchange module (the so-called agent centre) is the universal EHR infrastructure module. This enables data exchange and interoperability of all integrated users and delivers all messages which conform to the standard message type. Providing the users (medical personnel or patients) with message exchange and administration, the agent centre makes possible several rights and services, which make the system user-friendly: 1) central security solution, 2) administration of rights and users, 3) authentication and authorisation of users, 4) integration with external information systems (via X-road), 5) message administration and message-based integration 6) log-in (for example, for the online Patient Portal). Based on advanced IT-architecture, software solutions, security and accessibility technologies (ID-card authorisation), the EHR is innovative not only technologically but also in the sense of new public services, namely - public service innovation. The Patient s Portal which is being developed in the course of EHR enables the patient to access his/her medical data irrespective of time and place. 5. SUSTAINABILITY AND TRANSFERABILITY 5.1. Sustainability The EHR solution has a great future potential. The Estonian Government has emphasised the strategic importance of E-Health initiatives (Government Coalition Agreement, 2007), and the Ministry of Social Affairs has agreed different sources of financing for several follow-up activities at national level: for national healthcare institutions - directly or by performance contracts from the state budget (coordinator the Ministry of Social Affairs); for service-providers (clinics, hospitals, etc.) by allocations from Haigekassa (National Health Insurance Fund) according to the annual medical service agreements; for the development of new services and applications of EHR (e.g., content development of the Patient Portal) - by programming new projects (by E-Health Fund); for the expanding of integration of activities into local information systems, the Ministry of Social Affairs has started to prepare for calls for new projects. 12

13 The Ministry of Social Affairs intends to programme several EHR and e-health related follow-up projects for the EU Structural Funds period. These include: e- Ambulance, EHR data-monitoring module, statistics module, research module, e- school health, e-blood (donors register, blood preparation register), e-medical certificate, and LOINC (medical laboratories classifier and register). New activities and programmes will also involve new partners, educational institutions and research organisations. All new projects programmed for the EU Structural Funds period will be managed by the E-Health Foundation Transferability The Estonian EHR project is a globally unique health information system which encompasses the whole country, registers virtually all residents medical history from birth to death, and is based on the comprehensive state-developed basic ITinfrastructure. This concept of a nationwide integrated medical health information system covering the whole population is fully transferable only if all of the following preconditions are fulfilled: first, the existence of a nation-wide secured data-exchange platform; secondly, the application of the highest security standards for system accessibility and users authentication, signature and encryption; thirdly, enforcement of the national laws for collection and exchange of personal medical data. It is evident that implementation costs may differ case-by-case, but it is assumed that such a project should be based on the results of comprehensive feasibility studies. The concept of EHR (nationwide medical data exchange) and IT-architecture, particularly the platform-independent and service-oriented modular system is applicable to any other country if the basic public and private technical infrastructure and personal data protection laws meet the technical and security requirements. The E-Health Foundation has presented the Estonian e-health projects to several international seminars and conferences, for instance, in April 2007, at the conference Information technology and Telecommunications in the Baltic Sea and CEE region (Riga, Latvia). 6. CONCLUSIONS: MAIN SUCCESS FACTORS Four main success factors can be identified from this case study for similar e- government/e-health actions supported by the Structural funds: 1. The effective application of the e-health service has been achieved by using the highest possible security level for storing the health records in the nationwide IT system, and enabling access at any time from any location in the country. To achieve that, the importance of close cooperation and mutual trust between the counterparts should be stressed, and wide discussion in society encouraged. 2. It is of great importance that Estonia had developed and maintains a public e- services infrastructure; the relevant basic IT-infrastructure and digital identification solutions are established by the state (X-road and the ID-Card authorisation and digital signing certification system). 3. The active political leadership of the Ministry of Social Affairs gives ongoing 13

14 political support for elaboration of the sufficient legislative framework; the Ministry also actively interacts with the partners, as well as establishing consultation groups or bodies (e.g. the Council for EHR). 4. The visibility of EHR progress creates a positive impact on the partnership and policy-making institutions: open discussions and pro-active public relations-policy led by the Ministry of Social Affairs and the E-Health Foundation have created trust as well as attracting new partners from health care sector service providers, educational institutions (e.g. Tartu University), and public authorities (e.g. Estonian register of Causes of death). 14

15 PROJECT CONTACT DETAILS Contact person Name: Oliver Lillepruun Position: Project manager Organisation: Foundation E-Health Address: Lastekodu 6a Tallinn Estonia Telephone: Fax: Project s website: The information contained in this case study is up to date as of: September 2007 This case study has been prepared by Ruta Rannala in the framework of a study carried out by Technopolis Group on behalf of the European Commission. The contents and views expressed in this case study are those of the author(s) and do not necessarily reflect the opinions or policies of the European Commission. 15