An Overview of Current Estonian Health Information System Architecture Pitfalls and prospects Artur Novek Health and Welfare Information Systems Center/ IT architect 13.10.2017
Health and Welfare Information Systems Center (HWISC) HWISC is a ICT competence center founded on 1 st of January 2017 which consolidates the roles and responsibilities of former ICT department of Ministry of Social Affairs and Estonian ehealth Foundation.
MISSION Health and Welfare Information System Centre is the COMPETENCE CENTER of information and communication technology in health, social protection and labour field
VISION By 2020 HWISC is a center, with dedicated and committed employees and provides humanbased and cross-integrated ICT services
Main responsibilities Development of information systems, standards, databases and e-services Maintenance of services and infrastructure Providing information security Data analysis to support policy making, reporting, productivity monitoring and supervision
HWISC structure Director e-services Governance Information System Maintenance Information Security Data Analysis Supporting Services
AREA HWISC clients in the Ministry of Social Affaires ICT CONSOLIDATED NON- CONSOLIDATED HEALTH SOCIAL SECURITY LABOUR HEALTH BOARD AGENCY OF MEDICINES NATIONAL INSTITUTE FOR HEALTH DEVELOPMENT SOCIAL INSURANCE BOARD ASTANGU VOCATIONAL REHABILITATION CENTRE LABOUR INSPECTORATE MINISTRY OF SOCIAL AFFAIRS
Other clients and parties of HWISC Gender Equality and Equal Treatment Commissioner Agency Official Mediator Agency Estonian Health Insurance Fund Estonian Insurance Fund Unemployment Other ministries and agencies Estonian and EU habitants Estonian enterprises Local government Healthcare providers/hospitals...
Three pillars of HWISC HEALTH LABOUR SOCIAL SECURITY Health IS Estonian Healthcare Professionals IS Water and Health Safety IS Estonian Communicable Deseases IS Employment Policy IS Working Environment IS Work Inspection IS Social Security IS Social Services and Benefits IS EESSI
Estonian ehealth, where do you come from?
90-s. Local systems, focus on insurance invoices Restoration of Estonian independence Central health insurance fund Mandatory electronic bills to insurance fund 1992 1994 1996 1998 2000 2002 HIS ESTER in Mustamäe hospital HIS ESTER2 by social ministry HIS ESTER3 by social ministry AS Medisoft program for family doctors
2000 2010 health information exchange, focus on health data Planning of health data exchange started Project preparation (2003-2005) ehealth Foundation established ehealth Projects (2006-2008) eprescription 01.01.2010 2000 2002 2004 2006 2008 2010 X-road first services Funding decision by Ministry of Economic Affairs National HIS 18.12.2008 Electronic Health Record Digital Images Digital Prescription Digital Registration
Estonian ehealth Foundation organization 2005 2016 Health IS development and maintenance Ministry of Social Affars North Estonian Regional Hospital Tartu University Clinic East Tallinn Central Hospital Union of Estonian Medical Emergency Society of Family Doctors Estonian Hospital Association Estonian ehealth Foundation Board Services development Standards development Management board ENHIS Operation Support (Communication, accounting, HR, lawyer, security ) Administrators IT management Helpdesk Programmers
Estonian ehealth, where are you?
5 key features of Estonian healthcare Earmarked social insurance tax 13% flat rate top-up to all salaries State responsibility for insurance coverage Single public purchaser of services (Health Insurance Fund) Decentralized provider network private operators governed mostly by public entities Strong primary care Universal free access >50% of outpatient contacts One of the most cost-effective health care systems (perhaps) 3-time champion of bang-for-thebuck prize by Health Consumer Powerhouse (SWE)
Facts about e-services in Estonia 100% of schools and government organizations have broadband connection 79% of have computer at home (2013) mparking in main cities 83% of households have broadband connection (2014) 99% of bank transfers are performed electronically 96% of income tax declarations are made via the E-Tax Board (2014) 31% of votes were cast over the internet on (2014) 62% of persons have completed the e-census (2012)
Laws that regulate ehealth area 1. Health Care Services Organisation Act; 2. Statute of Health Information System (governments Statute no 131 August 14 th 2008); 3. The Statute no 53 September 17 th 2008 of Ministry of Social Affairs on The Composition of Data, Conditions and Order of Maintaining of the Documents Forwarded to the Health Information System; 4. Data protection law; 5. Public Information Act. All healthcare providers must send data to Health Information System Access only to licensed medical professionals (other persons have access to personal data in the HIS if such right arises from law) ID card for authentication and digital signature Patient has the right to close his/her own data collected in the central database (opt out) Patient can access their own data (Patient s Portal ) Patient can declare their intentions and preferences Patient can monitor visits to their HIS. (All actions will leave secure trail).
ehealth services in Estonia Health status summary for medical commission of Minstry of Defence 2017 Drug-drug interaction detection (2016) Health Insurance Fund Picturebank Collecting health service reimbursement invoices HWISC ~1995 Health insurance information ~2000 Digital picture archiving services 2005 Services for dental care (2015) eambulance services (2015) Medical certificate services (2014) Statistics services (2013) Cross-border Patient Summary (epsos 2013) econsultation services 2012 EHR services for physician and patient 2008 Digital registration services 2008 eprescription Services 2010 Health status summary for Social Insurance Board 2012
Three-layer development model of Estonian Health Information System Institutional and user level cooperation End-user software development and data exchange services Central System Database and related services User needs Process Descriptions Data sets Standards Legal Framework Training programs End-user software User Interface Data input Data Visualisation Data filters Data transmission Data transmission Central services External services Database model Infrastructure
Estonian ehealth architecture central DB-s FAMILY FAMILY FAMILY DOCTO DOCTO DOCTO RS RS IS IS RS ~800 PHARM PHARM ACIES ACY IS ACY IS ~500 SCHOOL NURSES 2010 september HOSPITALS ~60 ROAD ADMINISTRATION - Drivers licenses HEALTH INSURANCE DATABASE ~1995 PICTURE ARCHIVE 2005 NATION- WIDE HEALTH INFORMATION SYSTEM 2008 december PRESCRIPTION CENTRE 2010 january HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists STATE AGENCY OF MEDICINES - Authorized medicines - Handlers of medicines POPULATION REGISTER BUSINESS REGISTER
Major architectural decisions of current Health Information System Integration through Central system Opt-out policy in form patient can close data from doctors XML based HL7 v3 (extended) messages Documents are kept in XML format (HL7 CDA R2) All identifiers have OID-s Only final versions of clinical documents are sent into central system after case is closed Reuse of national infrastructure ID card for authentication and digital signature X-road for secure communication
Estonian ehealth architecture STATE AGENCY OF MEDICINES - Coding Centre - Handlers of medicines HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists POPULATION REGISTER BUSINESS REGISTER HEALTH INSURANCE FUND REGISTER Drug-drug Interaction database 2016 PRESCRIPTION CENTRE 2010 january QUALITY REGISTERS. Cancer. HIV. Myocardial infarction. Tuberculosis. Etc. FAMILY DOCTORS 2009 SCHOOL NURSES 2010 september HOSPITALS 2009 NATION-WIDE PICTURE ARCHIVE 2005 (national 2014) X-Road, ID-card, State IS Service Register VPN PATIENT PORTAL 2009 v1 2013 v2 DOCTOR PORTAL 2013 SOCIAL INSURANC E BOARD PORTAL 2012 X-ROAD GATEWAY SERVICE 2009 PHARMACIES AND FAMILY DOCTORS AMBULANCE SERVICES APPLICATION 2014 EMERGENCY SERVICE MOBILE WORKSTATIONS NATION- WIDE HEALTH INFORMATION SYSTEM 2008 december ANONYMIZED HEALTH DATA FOR STATISTICS 2013 STATISTICS PORTAL 2013
ehealth copies e-state architecture
Message layers on X-Road HL7 CDA document Digidoc HL7 interaction Healthcare provider IS National Central HIS X-Road message
Lab notice Swineflu Üldandmed notice Mari-Liis Infection Üldandmed 47595064059 Mari-Liis notice Männi 1-2 Üldandmed 47595064059 Discharge Tallinn letter Mari-Liis Männi 1-2 Demographics 47595064059 Mari-Liis Tallinn Diagnoos Männi punetised 1-2 47595064059 Diagnoos Tallinn Männi punetised 1-2 Allergia Tallinn Diagnoos õietolm Allergia punetised Diagnosis õietolm chickenpox Allergia õietolm Allergy pollen Document processing Agents Patient coding agent Find or create patient internal code Medical documents receiver agent Document: Lab notice, Discharge letter Health record agent Event: Medication, Diagnosis, Procedure Infection disease agent Diagnosis: chickenpox Demographics agent Address: Männi 1-2, Tallinn Patient index Medical documents Medical events Demographics Timecritical report agent Allergy: pollen Timecritical reports
Data in Health Information System Document registry Subject Demographics (alternative sources) Patient identity Patient index Identity 1 Identity 2 Identity 3 Patient portal Version 1 Version 2 Version 3 Population registry Medical documents Version 1 Version 1 Medical documents Consultation Image note reference Epicrisis Referral Referral answer Version 2 Version 1 Version 1 Version 1 Version 2 Medical events Diagnosis Operation Visit Prescription Procedure Version 2 Version 1 Version 1 Version 1 Version 2 Lasting care, diagnoosis, observation Pregnacy Encounter Blood group Allergy Status 1 Status 2 Status 3 Status 1 Status 2 Status 3 Status 4 Status 1 Status 2 Status 3 Status 4 Status 1 Status 2 Status 3 Status 4
Query processing Query Patient Mari-Liis 47595064059 Agents Patient coding agent Find patient internal code Patient index Record type Diagnosis Health record agent Find all diagnosis type records Medical events Patsient Mari-Liis 47595064059 Diagnosis Diagnosis Diagnosis Security agent Document open? Consolidate records Access rights Diagnosis: chickenpox Document no: 103 Hospital: PERH Warning, some documents are closed!
Client systems without Xroad server X-road gateway X-road s security Validation and surveillance data collection Business Logic Data Services Data Storage Technical solution Client systems Segmented LAN Activity Surveillance Portals VPN access gate Monitoring Statistics Client systems Hospital IS, GP IS 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
SECURITY & AUTHENTICATION
The 6 main principles 6 whales of security of Estonian Health Information 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, protected by blockchain 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 countermeasures (both organizational and technical)
Guardtime KSI (blockchain) Guardtime KSI is based on cryptographic hash functions and binary hash trees called also Merkle trees (https://en.wikipedia.org/wiki/merkle_tree). A global aggregation hash tree summarizing all requests is built every second and destroyed after all clients have received their hash chains. Only the root hashes are kept in public calendar blockchain which is special kind of hash tree that contains a time element. Guartime publishes periodically in public physical and electronic media its calendar blockchains root hash value.
STANDARDS
Standards HL7 v3 and DICOM (Picture Archive) International classification: ICD-10, LOINC, NCSP, ATC Estonian ehealth s OID registry Estonian ehealth classificators Published in publishing centre http://pub.etervis.ee Classificators are regulated by government act https://www.riigiteataja.ee/akt/12910889
Patient portal new design (live 2013 june)
Acceptance eprescription covers 100% of issued prescriptions. 98% are prescribed digitally, remaining 2% are entered in pharmacy. 97% of Hospital discharge letters are sent to the central DB. 60% of ambulatory case summaries 60% of dental care summaries are digital and sent to the central DB 1 348 468 person have documents in cetral DB
Documents and events in HIS 02.10.2017 Document type Count Out-patient consultation notes 17 600 757 Referral answer 8 349 730 In-patient consultation notes 1 757 791 Referral 1 373 830 Immunization notification 612 027 Children Health check notifications 461 076 Emergency care summary 443 448 Daycare consultation notes 299 238 Home nursing summary 7 321 Total 30 897 897 Event type Count Procedure 162 817 031 Analysis 77 740 361 Diagnosis 36 721 411 Encounter 35 652 393 Case 23 530 077 Observation 19 702 847 Immunization 1 713 909 Surgery 796 963
HIS usage per month Patient queries per month Healthcare professional queries per month Documents per month 1800000 1600000 1400000 1200000 1000000 800000 600000 400000 200000 0 2008.12 2009.03 2009.06 2009.09 2009.12 2010.03 2010.06 2010.09 2010.12 2011.03 2011.06 2011.09 2011.12 2012.03 2012.06 2012.09 2012.12 2013.03 2013.06 2013.09 2013.12 2014.03 2014.06 2014.09 2014.12 2015.03 2015.06 2015.09 2015.12 2016.03 2016.06 2016.09 2016.12 2017.03 2017.06 2017.09
eprescription 1.000.000 900.000 800.000 700.000 600.000 500.000 400.000 300.000 200.000 100.000 - ISSUED SOLD
European Hospital Survey: Benchmarking Deployment of е-health Services 2012 Deployment Composite Indicator comparison with 2010 index
European Hospital Survey: Benchmarking Deployment of е-health Services 2012 The Availability and Use Composite Indicator
Estonian ehealth, where do you get the money?
ehealth Foundation financing Expenditure Year ( ) 2005 6 853 2006 259 944 2007 462 193 2008 1 009 156 2009 1 178 362 2010 1 433 602 2011 1 834 204 2012 3 048 636 2013 3 293 680 Health Insurance Fund Healthcare Provider Taxes Ministry of Social Affairs ehealth Foundation EU Funds Ministry of Economic Affairs and Communication 12% 64% 24% 2013 Without EU financing 1/3 from HCP-s and 2/3 from Social Ministry
EU funded projects Estonian ehealth Foundation Electronic Health Record (1.6 mln ) Digital Registration (0.2 mln ) Digital Images (0.2 mln ) Activity surveillance module (0.4 mln ) Statistics module (0.4 mln ) Authentication and authorization module (0.2 mln ) elaboratory (0.2 mln ) Health Insurance Fund Digital Prescription (0.24 mln )
Estonian ehealth what did you learn?
Lessons learned Resources were planned only for central development. Usability is important. Developing process has to include medical competence users Data quality is important Complete and quality data give value Balance between security and usability PIN for every document
Digital stamp for family doctors 60000 Documents Sent by GPs in 2012 and 2013 (1st Quarter) 50000 40000 30000 20000 10000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Estonian ehealth, where are you going?
Estimated (qualitative) strength of the fiscal impact by core projects Reduced time waste during visit Less physical contacts Reduced rehospitalisation Reduced waste in IT development Improved prevention 1. Data quality 2. Data-driven and event-based ENHIS 2.0 3. Data capture 6. New patient portal 7. Clinical decision support 8. Personalized medicine 9. Patsient logistics 10. Healthcare process coordination 11. Integrated social and healtcare services 12. Monitoring of health services 13. Telehealth services
Next structure fund projects Funded Death certificate digitalisation State Agency of Medicines IS modernisation Digital registration (connecting hospitals) Digital referral and nursing summary Laboratory services management Applications planned 2018 Data-driven and event-base ENHIS 2.0 Health Board IS modernisation Health Board Laboratory IS phase II Health Board surveillance IS
Clinical decision support Ministry and Health Insurance Fund applied together for Enterprise Estonia support. Preliminary study done by Tallinn University of Technology. In parallel clinical pilot projects - Breast cancer - Cardiovascular diseases
Cross-border cooperation Connecting Europe Facility (CEF) ehealth Wave I ep (B) - EE, FI, SE, CR, PT - 2018 June Wave II ep (A) + PS (A & B) - 2019 March Electronic Exchange of Social Security Information (EESSI) Social Insurance Board - 2017 november
Thank You! Artur Novek artur.novek@tehik.ee