The Estonian Electronic Health Record System

Madis TiikCEO

Estonian e-Health Foundation

Baltic Congress in Laboratory Medicine 16 September 2010

Information SocietyBy 2013

All public services are digitaly availablePublic infrastruture is service oriented (x road)Digital authorisation of users, based on the ID

card, is the best available in the worldData is stored were it is collected and

exchange of the data is available thous who need it

Lifestyle

Self-help

Tele-advice AppointmentNotification

Prescription

Campaigns

PublicServices

Policy-making

Analysis

Diagnostics

Treatment

Guidlines

Follow-up

EHR

Workflow

Family doctors

Hospitals

Founders of the Estonian eHealth Foundation

End users

Strategy and Architecture Development

Marketing and Channel Management

Ministry of Social

Affars

East Tallinn Central Hospital

Tartu University

Clinic

Society of Family Doctors

North Estonian Regional Hospital

Management Board

Estonian eHealth Foundation

Board

EHR Operation

Estonian Hospital

Association

Union of Estonian Medical

Emergency

Nursing Care

Patient Portal

Health Authorities

Governance

Our tasksManagement of E-Health projectsStandardisation and development of medical

digital documentsMaintenance of the Estonian EHR system International cooperation and scientific

cooperation with universitiesDevelopment of new services for citizens and

doctors

Financed from the State budget (1.5 mln € – 2010)5

X-ROAD

SS

HEALTH CARE BOARD- Health care providers- Health professionals- Dispensing chemists

STATE AGENCY OF MEDICINES- Coding Centre

- Handlers of medicines

SS

SS

HEALTH INSURANCEFUND

Prescription Centre2010 january

HEALTH INFORMATION SYSTEM ( EHR)

17.12.2008

SS

SS

- Citizen Registry- Company Registry

SS

Pharmacis2010 january

Doctor’s and pharmacies

software solutions

Hospitals 2009

Family doctors2009

Emergency Medical Service

2011School nurses

2010 september

SS SSSS SS

Healthcare Provider

SS

Monitoring portalPatient portal

Goverment’s e-service frameworkwww.eesti.ee

KIT Citizen view

EIT Enterprice view

AIT Official’s view

W-SS

Estonian national eHealth infrastructure

Lab referalÜldandmed

Mari-Liis

47595064059

Männi 1-2

Tallinn

Diagnoospunetised

Allergiaõietolm

Swineflu notice

ÜldandmedMari-Liis

47595064059

Männi 1-2

Tallinn

Diagnoospunetised

Allergiaõietolm

Message

Timecritical reports

Demographics

Health recordInfection notice

ÜldandmedMari-Liis

47595064059

Männi 1-2

Tallinn

Diagnoospunetised

Allergiaõietolm

Discharge letterDemographics

Mari-Liis

47595064059

Männi 1-2

Tallinn

Diagnosischickenbox

Allergypollen

Demographics agentAddress: Männi 1-2, Tallinn

Infection decease agentDiagnosis: chickenbox

Timecritical report agentAllergy: pollen

Health record agentEvent: Medication,

Diagnosis, Procedure

HPIservices

Document processing

Statistics queryOutbreak report

Data integrationDemographics, health statusHPI

Health Portal DevicesInformation

Systems

Standards and Services

Processes and Integration

WSDL

XSD

Public IT Infrastructure

ConcentDocument

archive

Health record

StatisticsDecision Support

ReportsHealth status

Ambulance

Demo-graphics

Booking

EHR Central Functions

Storage ( long time archive)Metadata/ universal viewer

Current Situation 15.09.2010There are 1 858 541 documents in the Estonian

EHR Discharge letters (epicrises) 233 338 Out-patient consultation notes 338 922 Dispensed medication information 770 704 DICOM images ( index) 264 488 Image reports 243 797

More than 400 000 citizens have digital medical records in EHR , it is 30% of the population

Availability of Discharge LettersYear 2009

North Estonian Regional Hospital

Tartu University Clinic

East Tallinn Central Hospital

27661 31914 24038

82% 74% 84%

These 3 hospitals cover more than 60% of in-patient cases in Estonia

ePrescriptionsPrescription centre was launched 1st of January 2010

January February

March April May June July August

Number of e-prescriptions issued

278 957 407 609 520 000 387 000 381 836 408 713 386 493 435431% from prescriptions issued*

40% 58% 74% 55% 55% 58% 55% 62%

Purchasedprescriptions

150 009 221 800 322 000 288 000 292 207 318 968 314 414 333018% from purchased prescriptions*

21% 31% 46% 41% 42% 46% 45% 48%

*estimation based on 2009 numbers - 700 000 prescriptions monthly** 13.04 recomendation not to use e-prescription to the doctors

eLab projectTranslation of 10 000 LOINC termsImplementation LOINC and RELMA program's in all

labs Mapping of Lab’s test’s with LOINC standard.Influence to the other projects:

Enables data exchange between labs and healthcare providers

Enables statistical analyzes and comparisonsTest results are seen to all users of EHREnables patient’s to see lab testMore info for decision support Automatic exchange data with Infectious diseases register

Workflow of lab test’sDoctors IT system

Sample logistic

Lab

EHR

1.-2. Referal (patient ID, test specifikation, index number)

3. Referal (test specifikation, index number)

5. Lab test result(index number)

6. Report, alerts, lab test results

Referal centre

4. Sample + index number

Lab test standard

<observation classCode="OBS" moodCode="EVN"> <!-- eristab mis liiki Observation kirjega on tegemist--> <code code="ANA" codeSystem="1.3.6.1.4.1.28284.6.2.2.5.1" codeSystemName="Observation liik" displayName="Analüüsi tulemused"/> <!-- staatus: lõplik--> <!-- <statusCode code="completed" codeSystem="2.16.840.1.113883.5.14" codeSystemName="ActStatus"/> --> <statusCode code="completed"/> <!-- analüüsi vastuse rea aeg--> <effectiveTime value="20060501134139"/> <!-- analüüsi tulemus --> <value xsi:type="ED"> 9.2 </value> <specimen typeCode="SPC"> <specimenRole classCode="SPEC"> <specimenPlayingEntity classCode="ENT" determinerCode="INSTANCE"> <!-- analüüsi parameeter--> <code code="tO2" codeSystem="OIDnr" codeSystemName="Analüüside parameetrid" displayName="tO2"/> <!-- ühik --> <!-- code="" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM", kui võimalik--> <desc>Vol %</desc> </specimenPlayingEntity> </specimenRole> </specimen> <referenceRange typeCode="REFV"> <observationRange classCode="OBS" moodCode="EVN.CRT"> <!-- referentsväärtus--> <text>10 Vol %</text> </observationRange> </referenceRange></observation>

Analüüs, v2

Pakett: DL mallid

Detailid: Created on 30.08.2007. Last modified on.27.01.2010.

Selgitus: Lisatud analüüsi koht: targetSiteCode Lisatud SNOMED klassifikaator vers 2: Lisatud seos mallidega Toimingu teostaja asutus (0..1), Toimingu teostaja isik (0..1), lisatud analüüsi koodi klassifikaatoriks HK teenuste hinnakiri.

Seosed Atribuut Kordsus ja seos Selgitus referentsväärtus või väärtuste vahemik

0..1 ObservationRange text.

Reegel: väärtus või väärtuste vahemik

staatus (tehniline) 1..* Observation statusCode.

Klassifikaator: Staatus

vastuse tulemus 0..* Observation value.

observation liik (tehniline) 1..* Observation code.

Struktuur: vastavalt klassifikaatorile Klassifikaator: Observation kirje liik (tehniline) Reegel: code = "ANA" (analüüs) OID: Observation liik algusega 1.3.6.1.4.1.28284.6.2.2.5

parameetri mõõtühik 0..1 PlayingEntity desc.

analüüsi parameeter 0..1 PlayingEntity code.

analüüsi kood 1 Procedure code.

Klassifikaator: LOINC OID: LOINC : 2.16.840.1.113883.6.1 või: Klassifikaator: SNOMED OID: 2.16.840.1.113883.6.96 või: Klassifikaator: HK teenuste hinnakiri OID: 1.3.6.1.4.1.28284.6.2.1.6 codeSystemVersion: verisooni nimetus

http://pub.e-tervis.ee/standards2/Standards/3.0

Life Cycle of Digitization of Medical Document 12

mo

nth

s3

mo

nth

s3

mo

nth

s6

mo

nth

s

Task Setup Ministry of Social Affairs, EeHF, Professional Society’s

Content Related Standardization The Estonian eHealth Foundation (EeHF)

Technical Standardization – CDA documentDeveloper (Outsourcing)

Development of Central System Services Development of Health Care Service Providers’ Developer (Outsourcing) Information Systems

Health Care Service Provider’s ICT partner

Installation Standard to the Test Environment (EeHF)

Testing and Acceptance ServicesDeveloper, EeHF, Health Care Service Provider’s ICT partner

Ministerial degree naming the date for Health Care Providers when standard and new documentation is obligatory - Ministry of Social Affairs

Standard published, installed to working environment, new service in portfolio of EeHF- EeHF

Patient’s Portal → Personal Health Record (PHR) 2010-2011

• PHR – one view for citizens– Illness data from healthcare system (Patient’s Portal)– Self-monitoring data– Wellness data from third parties– Data from social system– Patient forums– Screening remainders

• Decision support – Self-care– Virtual health check

Future of EHR

Interactive Services

Viewing Prescriptions

Viewing Health Record

E-consultation

Immunization Passport

Virtual Health Check

Citizen Health Record

Collecting Personal Health Information

Self-help

Personal Data Management

Informational Services

Reminders

Invitation for Screening

Booking Service

Supporting Services

Rights Management

Authorizations

Expressions of Will

Access Rights

Log Archive

EHR Portal Services for Citizen

TIS

EHR

TIS

Decision Support

Knowledge Digitalization

Suggestions and

Reminders Decision Support Service

Decision Scripts

Health RecordsDigital Library

Health Records Service

DecisionSupport

CoreEngine

EBMeDS Local ServiceEstonian NHIS

HCIworkspace

EHRDocument

Service

Global, National & Local Scripts

Evidence Links

Function Library

Patient Data

Forms & Calculators

Response Messages

Drug Information• Best Practice• Contraindications• Interactions

Con

vers

ion

filt

ers

”Glu

e”

com

pon

en

t

EHR DecisionSupport

Web ServerApplication

EBMeDSEvidence-Based Medicine electronic Decision Support

HTTP

Web Resources• EBM Guidelines• Cochrane Library• Essential Evidence• EBMeDS Home Page

Script Editing Tools EBMeDSDatabase

EBMeDSMaster FilePackage

EBMeDS Central Service

Administrator Tools

TestingApplications

TestingApplications

Table Editing Tools

CompilingTools

JavaScriptInterpreter

Data Tables

FTP

LogFiles

UpdateService

Application Maintenance

Server, Storage & Network Management

Database management

Monitoring help desk

Application Operations

Hardware and Data Center

Application Development

Business Processes

Partners

eHealth

eHealth

Partners

ITIL

Maintenanceof Estonian EHR System

Application Development

Server, Storage & Network Management

DataBase Management

Monitoring, Help Desk

Application Operations

1

2

3

4a

4b

5

6

7

Hardware & Data Center

Maintenance of the EHR

Application Maintenance and Support

Business ProcessesBusiness Processes Doctor

s portal

Patient Portal

W-SSEHR

reguest servicis

Patient summary

Medication history

Incid

ent M

anagem

ent

Serv

ice R

equest

Managem

ent

Capacity

Managem

ent

Change a

nd R

ele

ase

Managem

ent

Pro

ble

m M

anagem

ent

Serv

ice Le

vel

Managem

ent

Serv

ice C

ontin

uity

M

anagem

ent

Opera

tions

Dem

and M

anagem

ent

Configura

cion

Managem

ent

Thank you for your attention!

Questions?

Madis.Tiik@etervis.eewww.etervis.ee http://eng.e-tervis.ee/

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