Problem: Fragmented flow of information between health providers; poor management of the growing number of patients with chronic care needs.
Solution highlights: A system-wide electronic health information system was introduced by the government and a national e-health foundation was established to guide change; development of e-health aligned with a broader government information strategy, enabling change and motivating necessary political support; early introduction of legislation provided a clear framework for activities and the Estonian Health Information System Development Plan 2005–2008 mapped out the change process; legislation coupled with aligned incentives encouraged widespread uptake of e-health by providers; partnerships with the private sector, universities and research organizations helped drive innovation; features of the electronic system (including electronic medical records, digital imaging, e-prescriptions and a patient portal) were gradually introduced and use of the system is now mandatory for providers.
Description of practice
In the late 1990s, flows of information between providers and across care levels were fragmented and providers often had to rely on patients for medical histories. However, with rising rates of chronic disease in Estonia, a growing need to improve management and continuity of care for patients with complex chronic conditions became apparent.
In the early 2000s, as part of an overarching strategy to establish an information society in Estonia, the government pushed for the development of an electronic national health information system. The Ministry of Social Affairs headed the project; adopting legislation, developing policies and creating the necessary regulatory framework to establish the Estonian National Health Information System (ENHIS). In 2005, the Estonian e-Health Foundation was created to coordinate implementation of ENHIS and oversee its management. Significant investments have been made to establish the necessary e-health infrastructure. Under the Foundation’s guidance, electronic medical records, digital imaging and e-prescriptions were gradually incorporated into ENHIS throughout the late 2000s, as detailed in the Estonian Health Information System Development Plan 2005–2008. Use of ENHIS by health providers and electronic submission of patient data is now mandatory. Private companies compete to develop the necessary software providers require to access ENHIS. Individual software systems chosen by providers connect to a central government data-exchange platform (X-road) which integrates and secures all data. X-road digitally records all interactions to strengthen accountability and secure access to information. Central storage of information allows ENHIS to serve as a coordinating tool for the health system, electronically connecting providers across care levels and disciplines for more integrated and streamlined services delivery. An online patient portal has also been incorporated into ENHIS to increase patient involvement in care, provide individuals with secure access to their health information and offer features such as online appointment booking. New applications to further engage, support and empower patients continue to be developed.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The Ministry of Social Affairs oversaw initial e-health planning efforts, passed legislation to enable change and devised the implementation strategy. The Estonian e-Health Foundation was created to assume management of the initiative via a multistakeholder board, allowing the Ministry to occupy a more supervisory role. The Foundation has created a unified platform for stakeholders and facilitated cooperation across different groups to give them an active role in steering the initiative. Technological innovations have been driven by the private sector with eight main companies competing to supply ENHIS-compatible software to providers. Providers maintain the necessary infrastructure to connect to ENHIS and have also established local working groups to support e-health implementation and services delivery improvements.
Monitoring data shows that use of ENHIS by providers is high, with 98% uploading patient information to the system. Over 90% of the population have documents recorded in ENHIS and over 90% of stationary case summaries and medical images are now uploaded. Additionally, the majority of prescriptions and hospital discharge letters are now sent digitally via ENHIS. Patient use of ENHIS is steadily increasing and approximately 140 000 monthly logins to the patient portal were recorded in late 2013. With ENHIS now well-established, the Estonian e-Health Foundation continues to explore ways to improve ENHIS and support the advancement of e-health and telemedicine.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Raul Mill
- Estonian e-Health Foundation
- Health care manager