Estonian e-health Artur Novek Estonian eHealth Foundation Implementation manager / Architect
Estonia
Estonia - 45 000 km2 1.29 mlj. Inhabitants
GDP: Agriculture Industry Service
2,7% 26,3% 74,5% 2
E-STATE ARCHITECTURE
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HEALTHCARE IN ESTONIA 30 hospitals 512 family doctors (juridical persons) Healthcare expenditures 2011 - 5.9% from GDP - 944.6 mlj. EUR
06.02.2013
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Estonian eHealth history Project preparation (2003-2005)
Planning initiated
2000
2002
2004
eHealth Foundation established
2006
Funding decision by Ministry of Economic Affairs
Electronic Health Record
Digital Images
Digital Prescription
eHealth Projects (2006-2008)
ePrescription 01.01.2010
2008
2010
National HIS 18.12.2008
Digital Registration 5
EU funded projects Estonian eHealth Foundation • Electronic Health Record (1.6 mln €) • Digital Registration (0.2 mln €) • Digital Images (0.2 mln €)
Health Insurance Fund • Digital Prescription (0.24 mln €)
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eHealth Foundation organization Ministry of Social Affars
Society of Family Doctors
Tartu University Clinic
East Tallinn Central Hospital
Union of Estonian Medical Emergency
North Estonian Regional Hospital
Estonian Hospital Association
Estonian eHealth Foundation Board Management board Standards development
Communication management
ENHIS Operation
IT management
Services development
Helpdesk
Administrators
Development levels of Estonian Health Information System
Institutional and user level cooperation
Data Exchange level different e-services
• • • • • • • • • • • •
Central System – Database and related services
• • • •
Partnerships User needs Training programs Process Descriptions Notifications User Interface User software Data input Data Visualisation Data filters (within user software) Web-interfaces Data transmission standards (HL7) Data set Data Standards Data filters relating to the central system Legal Framework
STANDARDS
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Standards • HL7 and DICOM (Picture Archive) • International classification: ICD-10, LOINC, NCSP, ATC • Estonian eHealth’s OID registry • Local eHealth classificators – Published in publishing centre – Classificators are regulated by government act https://www.riigiteataja.ee/akt/12910889 10
Standardization process Healthcare providers
Specialty assotiations
Social ministry Health Insurance Fund
EeHF standardization specialists
Terminology experts
HIS developers
UML+HL7 experts
Create data set
Formalize and merge UML model
Data set document
Classificators OID-s
XML schemas Description documents Examples
Stylesheets
Approve and publish Changes in NHIS documents regulatory act Fixed version of artifacts in publishing centre 11
EHR services for physician
Main services of the e-health in Estonia
EHR services for patient
Digital registration services
Services for Social Insurance Fund
eConsultation services Digital archiving services Cross Border Data Exchange services eAmbulance services
Supporting services
Services for dentaal care Services for blood center
Infrastructure services vi External services
Services for registers Services for nurse
Digital laboratory services
Subservices
A medical certificate services
Services for homecare Health information services for patient
Data and statistics services
E-learning services for medical staff
Analytics services for participants in treatment process
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Major architectural decisions of HIS • • • • •
Integration through Central system (Opt-out) XML based HL7 v3 (extended) messages Documents are kept in XML format (HL7 CDA R2) All structured data fields have OID-s Only final versions of clinical documents are sent into central system • Reuse of national infrastructure – ID card for authentication and digital signature – Xroad for secure communication
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X-ROAD GATEWAY SERVICE 2009
PATIENT PORTAL 2009 PHARMACIES AND FAMILY DOCTORS 2009 NATION- WIDE HEALTH INFORMATION EXCHANGE PLATFORM 2008 december
2011
EMERGENCY MEDICAL SERVICE
2010 september
SCHOOL NURSES
2010 january
PHARMACIS
2009
FAMILY DOCTORS
2009
HOSPITALS
BUSINESS REGISTER
POPULATION REGISTER
- Health care providers - Health professionals - Dispensing chemists
HEALTH CARE BOARD
- Coding Centre - Handlers of medicines
STATE AGENCY OF MEDICINES
Architecture
X-Road, ID-card, State IS Service Register
PRESCRIPTION CENTRE 2010 january
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SECURITY & AUTHENTICATION
06.02.2013
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The 6 main principles “6 whales” of security of Estonian eHealth system 1. 2. 3. 4.
5. 6.
A secure authentication of all users with ID-card or Mobile ID Digital signing or stamping of all medical documents A maximum accountability (transparency): all actions will leave an unchangeable (and unremovable) secure trail Coding of personal data: separating of personal data from medical data Encrypted database that allows to remove the confidentiality risk from the technical administrators Monitoring of all actions together with the corresponding countermeasures (both organizational and technical)
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HIS integration through X-Road HL7 CDA document
Digidoc
HL7 interaction
National Central HIS
Healthcare provider IS
X-Road message 17
Document processing Lab notice Üldandmed Swineflu notice Mari-Liis Üldandmed 47595064059 Infection notice Mari-Liis Männi 1-2 47595064059 Üldandmed Discharge letter Tallinn Mari-Liis Männi 1-2 Demographics 47595064059 Tallinn Mari-Liis Diagnoos Männi 1-2 punetised 47595064059 Diagnoos Tallinn punetised Männi 1-2 Allergia õietolm Diagnoos Tallinn Allergia punetised õietolm Diagnosis Allergia chickenpox õietolm Allergy pollen
Agents Health record agent Event: Medication, Diagnosis, Procedure Health record Infection disease agent Diagnosis: chickenpox
Demographics agent Address: Männi 1-2, Tallinn
Timecritical report agent Allergy: pollen
Demographics
Timecritical reports
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Query processing Query Patient Mari-Liis
Agents
47595064059 Record type Diagnosis
Patsient Mari-Liis
Health record agent Find all diagnosis type records
Health record
Security agent Document open?
47595064059 Diagnosis Diagnosis
Consolidate records
Diagnosis Diagnosis: chickenpox Document no: 103 Hospital: PERH Warning, some documents 06.02.2013 are closed!
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Client systems withoud Xroad server
Technical solution Client systems Portals
X-road gateway
Segmented LAN X-roads security
Validation and surveillance data collection
Business Logic
VPN access gate
Activity Surveillance
Monitoring Data Services Statistics Data Storage
• Client systems - HIS, GPIS • 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 20
PATIENT PORTAL (UPGRADE)
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Acceptance • • • •
ePrescription covers 94% of issued prescriptions. Over 90% of Hospital discharge letters – digital Over 95% of stationary case summaries have sent to the central DB Ambulatory case summaries sending – No certain rules for sending ambulatory case summaries! • 1 069 075 person have documents (82% of population)
Retrieval of Medical Documents by Healthcare Professionals
200 000
180 000
160 000
140 000
120 000
100 000
80 000
60 000
40 000
20 000
2013
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märts.13
jaan.13
nov.12
sept.12
juuli.12
mai.12
märts.12
jaan.12
nov.11
sept.11
juuli.11
mai.11
märts.11
jaan.11
nov.10
sept.10
juuli.10
mai.10
märts.10
jaan.10
nov.09
sept.09
juuli.09
mai.09
märts.09
jaan.09
Patient portal Number of queries
100000
90000
80000
70000
60000
50000
40000 Number of queries
30000
20000
10000
0
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26
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LEARNING POINTS
06.02.2013
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• Resources were planned only for central development. • Usability. 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 …
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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
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Better services • Faster data input – Voice recognition, statistics based text input assistant
• Faster and better output – Important information on “one screen” – Combining information from multiple sources – Graphical solutions – Precaching
• Single sign on 31
„App Store“
Tablet PC PC
Mobile
Integration platform
Notebook
RIS / PACS eHealth central system Hospital information system 32
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