Dr Ivi Normet

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Health Care and E-Health system in Estonia

• Dr Ivi Normet
• Deputy Secretary General on Health
• Ministry of Social Affairs

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Estonia

• Population 1.323 million
• Area 45 227 km²
• 15 counties, 215 municipalities
• Urban concentration 68
• POPULATION PROFILE
• Sex ratio 1.14 females/males (EU average 1.05)
• Age structure 0 14 years 16 (EU average 16)
• 65 years 18 (2012) ( EU average 18)

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Health system main actors

• Ministry of Social Affairs (MoSA)
• National agencies under MoSA
• State Agency of Medicines
• National Institute for Health Development
• Health Board
• Estonian Health Insurance Fund (EHIF)
• e-Health Foundation
• County governments
• Providers of care
• Research institutes
• Associations

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Health system financing

• Mainly publicly funded through solidarity based
  mandatory health insurance contributions in the
  form of earmarked social payroll tax (Bismarck).
• Employers are obligated to pay social tax for
  employees of which includes 13 of gross wages
  for health insurance.
• The health insurance system covers about 94 of
  the population.

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Health system financing

• Financing is mainly organized through the
  independent EHIF.
• EHIF finances outpatient and inpatient services
  provided to insured persons, and in certain cases
  also rehabilitation, nursing and dental care
  services.
• MoSA is responsible for financing emergency care
  for uninsured people, as well as for ambulance
  services and public health programs.
• Local municipalities have a minor, rather
  voluntary, role in organizing and financing
  health services.
• Private expenditure constitutes approximately
  20 of all health expenditure mostly in the
  form of co-payments for medicines and dental
  care.

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Health system financing

• Estonia spent 5.8 of its GDP on health.
• Total health care expenditures in 2012 in
  constant prices were 344.27 million euros.
• The share of public health expenditure in total
  health expenditure was 80.5 inl. EHIF (69.6).
• The share of households' out-of-pocket
  expenditure in total health expenditure was
  17.8.

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Health system Primary Care

• Since 1998 organized around family practices
  (before in polyclinics and ambulatories).
• sole proprietors or found companies.
• primary care is the first level of contact with
  the health system.
• every family doctor has a service area and
  maintains a list of patients.
• the practice list cannot exceed 2000 or be less
  than 1200. Once the 2000 persons limit is
  reached, an assistant family doctor has to be
  hired.

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Health system Primary Care

• All family doctors are required to work with at
  least one family nurse to stimulate compliance,
  the EHIF applies a coefficient of 0.8 on the
  capitation fee for family doctors working without
  a nurse 5 family physicians out of 802.
• A shift in responsibility from family doctors to
  nurses (chronically ill patients, pregnant women
  and healthy neonates).
• Planning and management of primary care access is
  organized in national level (since 2013 before
  county level).

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Health system Specialist care

• A person needs a referral from the family
  practitioner to visit most of the medical
  specialist.
• Hospitals (61)
• Joint stock companies or foundations
• mainly owned by the state or municipality (66)
• seven types (regional, central, general, local,
  special, rehabilitation, nursing hospital)
• Outpatient specialist care
• companies, foundations or sole proprietors.

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Legislation and policy documents

• Main Acts
• Health Services Organisation Act
• Health Insurance Act
• Communicable Diseases Prevention and Control Act
• Mental Health Act
• Medicinal Products Act
• Public Health Act.

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Legislation and policy documents

• National Health Plan (NHP) is the main policy
  document which was adopted by the government in
  2008.
• The aims is to integrate all existing sectoral
  health plans, strategies and development plans
  into one plan that presents linkages between the
  various stakeholders of the health system and
  other sectors.
• NHP contains measurable targets with specific
  indicators and a detailed list of activities that
  are directly linked to the state budget.

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Legislation and policy documents

• NHP has yearly multisectoral action plan in 5
  fields
• Social cohesion and equal opportunities
• Safe and healthy development of children and
  adolescents
• Healthy living, working and learning environment
• Healthy lifestyle
• Development of the health care system.

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Goals for e-health systems

• Decreasing the level of bureaucracy in the health
  care workers work process.
• Increasing the efficiency and improving the
  quality of the health care system.
• Making the time-critical information accessible
  for the attending physician.
• Developing more patient friendly health care
  services.

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Nationwide E-health system

• Launched 2008, after implementing four e-health
  projects
• Electronic Health Record (EHR)
• Digital Prescription
• Digital Image
• Digital Registration
• built on state IT infrastructure (uses same
  solutions ID card, X-road, etc.).
• all health care providers must send data to EHR
  according to law.
• multifaceted system- incl. technological,
  standardisation, legal, organisational and
  ethical aspects.

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eHealth

• Estonian eHealth Foundation
• Founded 18.10.2005 by main stakeholders
• Ministry of Social Affairs
• 3 biggest hospitals
• North Estonian Regional Hospital, Tartu
  University Hospital, East Tallinn Central
  Hospital
• The Estonian Society of Family Doctors
• The Estonian Hospitals Union
• Union of Estonian Emergency Medical Services

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eHealth EHR System

• All patients medical records are gathered from
  all healthcare providers into one central
  database that gives healthcare professionals a
  fast overview of patient diagnoses, medications,
  laboratory results, vaccinations and other
  personal data.

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eHealth EHR System

• EHR also enables
• patients to access their medical data through
  patient portal.
• to see anonymous but still individual based
  information for statistics and research purposes
  as well as for improving health service and
  measuring quality of treatment.
• The coverage of inpatient data in EHR is 100 and
  70-80 on outpatient data but its improving all
  the time.

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E-Health e-prescription

• e-prescription (2010) aim was to
• satisfy the rising patient expectations (to get
  the same prescription without visiting doctor)
• strengthen ingredient-based prescribing (from 50
  in 2010 to 75 in 2012) gt OOPP decrease for
  medicines
• economize doctor's, pharmacist's, patient's time
  gt pre-filled fields (reimbursement rate, former
  prescription history)
• make detailed analyses of the use of medicines.

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Challenges and directions of developments

• Sustaining health expenditure and human resources
  at levels that ensure timely access to and high
  quality of care.
• This is particularly important in the face of
  rising patient expectations, ageing of the
  population (age related morbidity, less financial
  resources) and as well as increase of cost and
  volume of health care services.

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Challenges and directions of developments

• Centralization of more sophisticated and high
  technology special care (competence centres).
• Decentralization of frequently needed and more
  simple care (primary care, some special care).
• Concentration to out-patient and day care.
• To rise the number of state commissioned
  education study places for health care workforce.

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Challenges and developments Strengthening of
primary health care

• by creating the network of health centres to
  provide wider scale of services (family
  practitioner and nurse, home nursing, midwife,
  physiotherapist, dentist and also integration of
  public health services etc), to assure good
  access and cover the needs of ageing population.

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Challenges and developments Network of health
centres

• Restructuring county hospitals into multiprofile
  health centres by optimisation of ineffective
  services and integrating limited range of special
  care and diagnostic services with primary health
  care services into one infrastructure.

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• Thank you for your attention!