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 1st 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 human-
based and cross-integrated ICT
services
 Main responsibilities
• Development of
information
systems,
standards,
• databases and • Providing
e-services information
security
• Maintenance of
services and • Data analysis to
infrastructure support policy
making,
reporting,
productivity
monitoring and
supervision
HWISC structure

Director

Information
e-Services Information Supporting
System Data Analysis
Governance Security Services
Maintenance
 AREA

HWISC clients ICT

CONSOLIDATED

in the Ministry of Social Affaires NON-

CONSOLIDATED

SOCIAL
HEALTH LABOUR
SECURITY

SOCIAL INSURANCE LABOUR

HEALTH BOARD
BOARD INSPECTORATE

AGENCY OF ASTANGU VOCATIONAL

MEDICINES REHABILITATION CENTRE

NATIONAL INSTITUTE
FOR HEALTH
DEVELOPMENT

MINISTRY OF SOCIAL AFFAIRS

Other clients and parties of HWISC
• Gender Equality and Equal • Other ministries and agencies
Treatment Commissioner Agency • Estonian and EU habitants
• Official Mediator Agency • Estonian enterprises
• Estonian Health Insurance Fund • Local government
• Estonian Unemployment • Healthcare providers/hospitals
Insurance Fund
• ...
Three pillars of HWISC
SOCIAL
HEALTH LABOUR
SECURITY
Health IS Employment Policy
Social Security IS
IS

Estonian Healthcare
Professionals IS
Working Social Services and
Environment IS Benefits IS
Water and Health
Safety IS

Estonian Work Inspection IS EESSI

Communicable
Deseases IS
 Estonian
eHealth,

where do
you come
from?
 90-s. Local systems, focus on
insurance invoices
Restoration of
Estonian
independence
Mandatory
Central health electronic bills to
insurance fund insurance fund

1992 1994 1996 1998 2000 2002

HIS ESTER in HIS ESTER2 HIS ESTER3

Mustamäe by social by social
hospital ministry ministry

AS Medisoft
program for
family doctors
 2000 – 2010 health information
exchange, focus on health data
Planning of Project eHealth eHealth
ePrescription
health data preparation Foundation Projects
01.01.2010
exchange started (2003-2005) established (2006-2008)

2000 2002 2004 2006 2008 2010

X-road first Funding decision by Ministry National HIS

services of Economic Affairs 18.12.2008

Electronic Digital Digital Digital

Health Record Images Prescription Registration
Estonian eHealth Foundation organization
2005 – 2016 Health IS development and maintenance
Ministry North Estonian Tartu East Tallinn Union of Society of Estonian
Regional University Central Estonian Family Hospital
of Social
Hospital Clinic Hospital Medical Doctors Association
Affars Emergency

Estonian eHealth
Foundation Board

Management
board
Services
development
IT
ENHIS Operation management
Standards
development
Administrators Programmers

Support
(Communication,
accounting, HR, lawyer, Helpdesk
security… )
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-the-
buck” 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 14th 2008);
3. The Statute no 53 September 17th 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 Insurance Fund

Picturebank
 Collecting health service
reimbursement invoices HWISC
 Health status summary for ~1995
medical commission of Minstry  Health insurance
of Defence information
2017 ~2000
 Digital picture
 Drug-drug interaction archiving services
detection (2016) 2005

 EHR services for

 Services for dental
physician and patient
care (2015)
2008

 eAmbulance  Digital registration

services (2015) services
2008
 Medical certificate
services (2014)  ePrescription Services
2010
 Statistics
services (2013)  Health status summary for
Social Insurance Board
 Cross-border Patient  eConsultation 2012
Summary (epSOS services
2013) 2012
Three-layer development model of Estonian Health
Information System
• User needs
• Process Descriptions
Institutional and • Data sets
• Standards
user • Legal Framework
level cooperation • Training programs

• End-user software
End-user software • User Interface
development and • Data input
• Data Visualisation
data exchange services • Data filters
• Data transmission

Central System • Data transmission

Database and • Central services
• External services
related services • Database model
• Infrastructure
Estonian eHealth architecture central DB-s
FAMILY
FAMILY PHARM
PHARM
FAMILY PHARM
DOCTO
DOCTO ACY IS
ACIES
DOCTO ACY IS SCHOOL NURSES
RSIS
RS IS ~500
RS ~800 2010 september

HOSPITALS ROAD
~60 ADMINISTRATION
- Drivers licenses

HEALTH INSURANCE PICTURE

DATABASE ARCHIVE
~1995 2005

NATION- WIDE
HEALTH PRESCRIPTION
INFORMATION CENTRE
SYSTEM 2010 january
2008 december

HEALTH CARE BOARD

- Health care providers STATE AGENCY
- Health professionals OF MEDICINES
- Dispensing chemists - Authorized medicines
- Handlers of medicines

POPULATION BUSINESS
REGISTER 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
 STATE AGENCY OF MEDICINES
- Coding Centre

2013 v2
2009 v1
PORTAL
PATIENT
- Handlers of medicines

HEALTH CARE BOARD

- Health care providers

2013
- Health professionals
- Dispensing chemists

PORTAL
DOCTOR
POPULATION REGISTER

2012
SOCIAL

PORTAL
E BOARD
INSURANC
BUSINESS REGISTER

HEALTH INSURANCE

2009
FUND REGISTER

X-ROAD

SERVICE
GATEWAY

DOCTORS
AND FAMILY
PHARMACIES
PRESCRIPTION
CENTRE
2016

2010 january
database
Drug-drug
Interaction

2014
QUALITY REGISTERS.

MOBILE
Cancer. HIV. Myocardial infarction.
SERVICE
SERVICES

Tuberculosis. Etc.
AMBULANCE

APPLICATION

EMERGENCY
X-Road, ID-card, State IS Service Register

WORKSTATIONS
FAMILY DOCTORS
2009

SCHOOL NURSES
HEALTH

SYSTEM

2010 september
2008 december
INFORMATION
NATION- WIDE

HOSPITALS
2009
Estonian eHealth architecture

NATION-WIDE
PICTURE ARCHIVE
STATISTICS
VPN

PORTAL 2013

2005 (national 2014)

HEALTH DATA
ANONYMIZED

FOR STATISTICS
2013
eHealth copies e-state architecture
 Message layers on X-Road
HL7 CDA
document
HL7
interaction
Digidoc

Healthcare provider IS National Central HIS

X-Road message
 Document processing
Agents
Patient coding agent
Find or create patient Patient index
internal code
Lab notice
Medical documents receiver agent
Üldandmed
Swineflu notice
Mari-Liis Document: Lab notice,
Üldandmed Discharge letter Medical documents
Infection 47595064059
notice
Mari-Liis
Männi 1-2 Health record agent
Üldandmed
47595064059
Discharge letter
Tallinn
Mari-Liis Event: Medication, Diagnosis,
Männi 1-2
Demographics Procedure
47595064059
Tallinn
Mari-Liis
Diagnoos
Männi 1-2
punetised Medical events
47595064059 Infection disease agent
Diagnoos
Tallinn
Männi 1-2
punetised Diagnosis: chickenpox
Allergia
Tallinn õietolm
Diagnoos
Allergia
punetised
õietolm
Diagnosis
Demographics agent
chickenpox
Allergia Demographics
Address: Männi 1-2, Tallinn
õietolm
Allergy
pollen

Timecritical report agent

Allergy: pollen Timecritical reports
Data in Health Information System

Subject Patient index

Document
registry Patient
identity
Identity 1
Identity 2
Identity 3
Demographics (alternative sources)

Patient Population Medical

portal registry documents
Version 1
Version 2 Version 1 Version 1
Version 3

Medical documents
Consultation Image
Epicrisis Referral Referral answer
note reference
Version 1 Version 1 Version 1
Version 2 Version 2

Medical events
Diagnosis Operation Visit Prescription Procedure

Version 1 Version 1 Version 1

Version 2 Version 2

Lasting care, diagnoosis, observation

Pregnacy Encounter Blood group Allergy

Status 1 Status 1 Status 1 Status 1
Status 2 Status 2 Status 2 Status 2
Status 3 Status 3 Status 3 Status 3
Status 4 Status 4 Status 4
 Query processing
Query
Agents
Patient
Patient coding agent
Mari-Liis Find patient internal code Patient index
47595064059

Record type Health record agent

Find all diagnosis type
Diagnosis Medical events
records

Patsient Security agent

Mari-Liis Document open? Access rights
47595064059

Diagnosis Consolidate records

Diagnosis
Diagnosis
Diagnosis: chickenpox
Document no: 103
Hospital: PERH

Warning, some documents

are closed!
Client systems
without Xroad
Technical solution
server Client
systems
X-road Portals • Client systems – Hospital IS, GP
gateway Segmented LAN IS
• Patient portal - Oracle Portal,
X-road’s 2013 change to Tomcat
security VPN access
gate
• xRoad Gateway – MISP (Tomcat)
Validation and
• Activity Surveillance - Tomcat,
surveillance data Sybase IQ, Webfocus
collection
Activity
• Business Logic - Webmethods
Surveillance
Business Integration Server and Broker
Logic • Data Services - Oracle DBMS
Monitoring with Advanced Security and
Data Database Vault
Services
• Monitoring - Nagios, Cacti
Statistics
• Statistics –Iway Service Manager,
Data Storage
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 counter-
measures (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.e-
tervis.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 Event type Count

Out-patient consultation notes 17 600 757 Procedure 162 817 031
Referral answer 8 349 730 Analysis 77 740 361
In-patient consultation notes 1 757 791 Diagnosis 36 721 411
Referral 1 373 830 Encounter 35 652 393
Immunization notification 612 027 Case 23 530 077
Children Health check notifications 461 076 Observation 19 702 847
Emergency care summary 443 448 Immunization 1 713 909
Daycare consultation notes 299 238 Surgery 796 963
Home nursing summary 7 321
Total 30 897 897
 0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
1800000
2008.12
2009.03
2009.06
2009.09
2009.12
2010.03
2010.06
2010.09
2010.12
2011.03
Patient queries per month

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
Healthcare professional queries per month

2014.09
2014.12
2015.03
2015.06
2015.09
2015.12
HIS usage per month

2016.03
2016.06
Documents per month

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 (€) Taxes EU Funds
2005 6 853
2006 259 944
2007 462 193 Health Insurance Fund Ministry of Ministry of
2008 1 009 156 Social Affairs Economic Affairs and
2009 1 178 362 Communication
2010 1 433 602
2011 1 834 204 Healthcare Provider
2012 3 048 636 12% 64% 24% 2013
2013 3 293 680 eHealth Foundation

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

Documents Sent by GPs in 2012 and 2013 (1st Quarter)

60000

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
Less physical Reduced Reduced waste in Improved
waste during
contacts rehospitalisation IT development prevention
visit
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