Estonia leads the way in digital health reform

6 minute read

Dr Priit Tohver, an expert in how Estonia turned itself into a digital powerhouse, will speak at the WildHealth Sydney Summit.

Estonia has become a digital health powerhouse, regarded by many as having the best digital infrastructures in the world. Its pioneering approach to growth through innovation has positioned Estonia among global leaders in core next-generation technologies.

How that happened was the subject of a conversation HSD publisher Jeremy Knibbs and I had with Dr Priit Tohver in the lead-up to the WildHealth Sydney Summit on 11 September, where Dr Tohver will be a special guest.

He is the Head of Quality Services at the North Estonia Medical Centre, Estonia’s largest healthcare provider, serving half the population and dealing with the most complex medical cases in the country. His role is to ensure that the care provided at NEMC achieves the triple aim of being highly effective, highly safe and highly patient-centric, while being locked in on continuous improvement. Priit has previously served as the advisor for e-services innovation and development at the Estonian Ministry of Social Affairs and an advisor for health, trade and development for the Estonian permanent representation to the UN and other international organisations in Geneva. He is the former regional director for Europe at the International Federation of Medical Students Associations and a passionate advocate for global health.

We are excited he is coming to Sydney to share Estonia’s journey. The video below is an interview with Dr Tohver from 2019.

I admit Jeremy and I went into our chat with Dr Tohver with a few preconceptions about Estonia, its culture and what drove Estonians to create a digital economy. Some of those preconceptions were dispelled.

The origin story of all things digital in Estonia

Estonia became independent in 1991. It found itself in a tricky position – it was surrounded by legacy systems and did not have a lot of resources. The government realised that this situation, as precarious as it was, presented a unique opportunity to do things right.

The government brainstormed long and hard on how to transform the country into the digital juggernaut it is today. If you put yourself in Estonia’s shoes, you can see that this was very hard to do. When you get independence and have a ship to steer, all you want to do immediately is gain control, ensure that the ship doesn’t sink, take it to auto-pilot, and then think about other things, right? 

Thankfully Estonians did not give in to the pressure. They knew this was an opportune time to start afresh. And they went down the road where all good things should start – policy. 

After independence in 1991 Estonia modernised its digital infrastructure aided by prosperous Nordic states Finland and Sweden.

In the early 2000s the country introduced electronic identification and interoperable data exchange which were the two pillars that were essential to digitising the healthcare system.

“Once we started digitising health in 2008 our first step was to create a national electronic health record, and this was very much built on those two pillars,” said Dr Tohver.

“From that point we began adding services with electronic prescribing added in 2010, then we added multidisciplinary team care between doctors and specialists for the more complex case management, allowing family doctors to do consultations with 21 different specialties on a family doctor level.

“We then we added e-ambulances, digitising ambulance records with iPads in each ambulance, allowing ED doctors to enter an ID code into the system to retrieve essential data including prescriptions, allergies, and pre-existing conditions, before the patient arrives.”

In 2017 milestone decision supports in drug interactions were added to the system. In 2019 a centralised electronic booking system across all hospitals was introduced, which allowed doctors to see available appointments of specialists in any hospital in Estonia. This initiative has substantially reduced waiting times to see a specialist.

“We have recently started exchanging electronic data across borders, exchanging prescriptions with Finland and also Croatia and Portugal, and we’re adding countries all the time so working on cross border exchange,” said Dr Tohver.

So what does this mean for the citizens of Estonia?

“One hundred percent of our citizens have digital longitudinal health records accessible throughout the country,” said Dr Tohver.

“Ninety-nine percent of our prescriptions are digital.

“Not only the patients, but even their guardians can access patient information if authorised. You can block or unblock access to your health information whenever you want.

“And finally, we have not had a system down time since 2001.” 

So what did Estonia learn on its digital health journey?

“We have learned that you don’t need to spend billions on an EHR. Estonia didn’t have the money to do this. In Estonia we spent about 1.3 million instead of 1.2 billion,” said Dr Tohver.

“Most of the work really is in the change management, so you must have the political leadership, and the healthcare advocates on your side.

“That’s why digital health starts with people actually understanding digital technologies, being tech savvy and being able to navigate the digital space.”

Dr Tohver told us that national digital skills training as well as digital awareness campaigns at a country-wide level was key. In the 1990s, every Estonian school had a computer class and there were public campaigns to improve digital literacy and cybersecurity awareness.

“The fact that Estonia digitised the entire state and not just healthcare, meant we could leverage a lot of the power across government with everyone playing a part in this change management,” he said.

“We engaged in a multi-stakeholder strategy to ensure we all agreed on the end goals rather than having a government dictate what the end goal was.

“It was agreed together with doctors, patients and policymakers. Having those conversations was very important. We worked together to achieve those goals and principles were in place about how the healthcare system should work.

“Then we designed the technology around it.”

Dr Tohver will be sharing how all of this innovation is improving the lives of the citizens of Estonia at the WildHealth Sydney Summit on 11 September.

Joining Dr Tohver on our panel discussing Estonia versus Australia will be Kate Ebrill, the interoperability lead at the Australian e-Health Research Centre, Ryl Jensen, who wrote two papers on Estonia in 2020, and Dr Natalie Thorne, scientific director of Genomical.

To find out more about and to register see ‘Australia vs the world’ digital health summit.

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