You can change the system: How Estonia has built the most advanced eHealth system in the world
Posted on March 09, 2015
by Noah Nemoy
Perhaps the best thing about being a MaRS based start-up is attending the guest lectures. MaRS regularly hosts global experts in science and technology, and their discussions are extremely enlightening. Last month’s lecture, given by the former CEO of the Estonia eHealth Foundation Dr. Madis Tiik, was no exception. A common frustration with mHealth start-ups is that the healthcare systems they operate under are rigid, monolithic, and resistant to change. However, Dr. Tiik’s inspiring presentation showed that a nationwide eHealth system is indeed possible.
Since Estonia implemented their Health Information Exchange (HIE) in 2009, it has been a resounding success. The HIE is used by over 98% of its population and national healthcare costs have fallen to 6% of GDP, making it Europe’s most cost effective. 99.5% of prescriptions are renewed online through ePrescription. Recognizing that patients get most of their health information online, eClinic provides users with online information from doctors, nurses, and medical specialists. User/patients after accessing the information, opt for self-care 80% of the time, further decreasing healthcare costs. Remarkably, HIE cost a mere €10 million or €7.5 per citizen to establish.
As Dr. Tiik explained, much of the HIE’s success is from its design. All medical documents since 2009 are uploaded into the system; such as time critical data, doctor visits, and medical images. The government oversees the system to ensure access rights requirements are met by both the provider and user, and conducts yearly audits to improve it. Two important failsafe’s have been built in to protect it from cyber-attacks; the system is self-sustained with no single point of entry, and all log-ins are monitored to see if they match the data they’re attempting to access before permitting access.
Despite HIE seeming like an impossible accomplishment, Estonia had several pre-conditions for its success. In 2001, the Estonian government decided that by 2013 all public services would be digitally available. Digital IDs were created for its citizens and legislation was enacted to protect their privacy. By 2009, the general public was receptive to eHealth, as eBanking, eVoting, and ePassports were commonplace, and there was a nationwide digital infrastructure it could be built upon. Additionally, in response to several major Russian cyber-attacks the past decade, Estonia developed the best cyber-security in all of Europe and is the NATO centre for online privacy.
But according Dr. Tiik, the most significant reason for Estonia’s success was that the citizens/users own their data. In most other nations the data is owned by the institution. Estonian users can decide how much of their data is shared and can opt out entirely. When medical professionals access patient data, it is tracked by the system. The user can see who is accessing their medical information and has the legal right to ask for the reason, further providing patients with transparency and privacy. One major lesson Dr. Tiik stressed is “citizens are happy to share their personal data, as long as it is secure and they are in control.”
Another interesting fact was that despite top-down systems being resistant to change, some of Estonia’s success was because of its top-down approach. Doctors resisted HIE, but because it was government mandated, they had to accept it. To decrease costs, the government decided to simply not to upload any old paper records. Unlike most eHealth systems where patients are encouraged to opt-in, all Estonians were put in the system and had to opt-out to leave, leading to a higher user retention rate. Conversely in Finland, municipalities each established a bottom-up eHealth system and are now going through a costly integration of their systems.
As an employee for a Canadian mHealth start-up, the first thought inspired by Dr. Tiik was that I should immigrate to Estonia immediately. But by the end of his lecture I realized it is not a question of if these changes will come to North America, but a question of when. His work has proven that a national eHealth system can be created, adopted, and provide more efficient outcomes to its citizens. Like other MaRS guest speakers from other nations, he showed us what was possible for us to accomplish here in Ontario. These guest lectures help show us what the end of the roadmap can be; it’s now up to us start-ups to get to work taking us there.
NOAH NEMOY M.Sc.
TEAM LEAD COMMUNICATIONS
With an MSc in the Theory and History of International Relations from the London School of Economics, Noah brings several years of communications experience to MEMOTEXT. Prior to joining, he worked for the Government of Ontario, several small businesses, and most recently on the winning campaign in the 2014 Toronto mayoral election. As someone who loves communicating good ideas to help make the world a better place, Noah is thrilled to be a part of the MEMOTEXT team.