National Audit Office
Tallinn, 5 February 2014 – The National Audit Office is of the opinion that the Ministry of Social Affairs should deal with the development of the e-health system more forcefully, as the initially planned objectives have still not been achieved. Despite the initial plans, data in the e-health system cannot yet be fully used for treatment purposes, national statistics, registry-keeping or supervision. Digital Prescription is the only e-solution created by the state that is actively used. The use of the Electronic Health Record and Digital Image has been modest and Digital Registration has not taken off in the five years since its completion. 15 million euros has been spent on launching e-health so far.

Digital Prescription is the only one of the four main e-health projects that has been launched in full. It was developed by the Estonian Health Insurance Fund. It proved successful because the fund itself was interested in its implementation, the focus was on one major project until it was implemented, and as many standard solutions as possible were used.

The Estonian e-Health Foundation has dealt with the implementation of the other e-health projects – the Electronic Health Record, Digital Registration and Digital Image.

The National Audit Office is of the opinion that the Electronic Health Record has not taken off as planned, because not all data are entered in the system, although this has been required by law since 2008. For example, 92% of providers of specialist medical care services (incl. hospitals and dentists) did not send any data to the Electronic Health Record in 2012 and half of those who did so only sent a quarter of the required data. If all data are not sent to the Electronic Health Record, the record cannot be used in everyday treatment and the broader goal of e-health, which is to make the organisation of health more efficient, cannot be achieved. Using the Electronic Health Record and other e-health applications would help doctors, nurses and patients save time and health insurance money, as all data would be in the same place and there would be no need for additional visits or tests. Although the requirement to submit data has been in effect for five years, the state has still not imposed any sanctions for failure to send treatment documents to e-health. The National Audit Office admits that submission of data to the Electronic Health Record increased during the audit in 2013 as more and more doctors and institutions do so. However, when it comes to making health care more efficient, submission of data is not the only thing of importance – the data should also be viewed and the audit indicated that there are very few instances when data in e-health are viewed.

Digital Registration, which was completed in 2008, has never started to work. There is still no central system for making an appointment with a doctor in which a patient can pick a suitable time to see any doctor at any hospital. The lack of such a system wastes health resources and the time of patients. The main reason why Digital Registration has not taken off is the lack of interest among health service providers.

Digital Image is still not a database in which all medical images are stored. Digital Image is simply a place where references to the locations of images are stored. The image itself cannot be viewed in the system. Also, not all health authorities submit references to the locations of images. One of the reasons for this is that two regional hospitals established by the state started developing their own system – the Image Bank – at the same as Digital Image was created, and 80% of the medical images taken in Estonia are currently located therein. This means that Digital Image has no value at present, as the images are located elsewhere and they are also viewed and used elsewhere.

The National Audit Office is of the opinion that the reason behind the weak launch of e-health is the aimless and random activities of the Ministry of Social Affairs in the development and implementation of e-health. The ministry, whose duty should be to represent the interests of the state, has mostly been an onlooker in the management of e-health; the other members of the supervisory board of the e-Health Foundation, who represent health service providers, have participated much more actively. The development of other services in addition to the four main projects launched on their initiative has reduced the attention and money given to the main projects. The National Audit Office is of the opinion that there is no way to know how long it will take to complete the pending projects.

Director of Audit of the Performance Audit Department Tarmo Olgo believes that e-health could be implemented in full in the future, but only if it is developed on the basis of the interests of the state and society. In order to make e-health an everyday tool for patients, doctors and public authorities, it is necessary to terminate projects that are still not working before new projects are launched and demand that all health service providers submit data to e-health and use the system in the future.

The Minister of Social Affairs promised to give a more detailed description of the activities required to achieve the objectives set for e-health. The Minister of Social Affairs and the Health Insurance Fund are also considering tying the use of the e-health system to payment for health services in order to boost use.

Four main projects are covered by e-health: Electronic Health Record; Digital Image; Digital Registration; and Digital Prescription. The first three were developed by the Estonian e-Health Foundation, while Digital Prescription was created by the Estonian Health Insurance Fund. 15 million euros has been spent on the development of e-health, instead of the initially planned 2.8 million euros. In addition to the main e-health projects, several other services have been developed at the same time, such as e-consultation, a statistics module and e-ambulance.

The purpose of the audit was to assess whether the objectives set for e-health – a higher quality of health service and the more efficient organisation of health care – have been achieved. The four main e-health projects were reviewed in the audit. The problems encountered in the development and implementation of e-health and their reasons were also investigated. No opinion on the completion of e-health in terms of IT or its security was given in the audit.

Toomas Mattson
Head of Communication Service, National Audit Office

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